Event Analysis Lessons learnt from Medication Reconciliation activities using Event Analysis to improve medication safety Evonne Fong, Dale Mitchell, Stephen Lim Pharmacy Department

Background Medication Reconciliation (MR) since 2007 at AHS ?? How and what to measure??  SQuIRe Compliance with MR processes on admission, transfer and discharge Varying results Admission: approximately 50% of patients with MR done within 24 hours Discharge: approximately 70% of patients with discharge reconciliation done  KPIs What we found: 17.2 medication errors per 100 medications a patient takes 58.4 drug errors per 100 high risk patients

Where to next?? … High 5s  AHS joined WHO’s High 5’s Project in 2009 Global patient safety collaboration Australia’s project: Assuring Medication Accuracy at Transition Points of Care  Benefits…. New measures High 5s MR 1-4 **Event Analysis**

New High 5’s measures 1.Percent of patients with meds reconciled within 24 hours of admission 2.Mean number of outstanding undocumented intentional medication discrepancies per patient 3.Mean number of outstanding UNINTENTIONAL medication discrepancies per patient 4.Percent of patients with at least ONE outstanding unintentional discrepancy

Event Analysis (EA)  Unprecedented opportunity to obtain and analyse findings from around the world regarding safety and effectiveness of SOP Contributing factors Any specific system changes needed Unique? Similar? Why?

Event Analysis (EA) Includes: Description of event Analysis of cause and effect Identification of contributing factors Recommended improvements in processes/systems Documentation of findings and recommendations

Example – Ian’s Story Day 1:  Admitted to ED on 22/5/2013 (Wednesday)  Admission reason: mechanical fall for investigation and rehabilitation + ?UTI  PMH: HTN, Parkinson’s Disease, neuropathic pain, depression  Pt unable to give accurate medication history  Pt transferred to acute medical unit  MO writes up medications on chart  Patient’s mobility assessed on the day of admission by physio

Example – Ian’s Story Day 2:  Patient transferred to General Medical ward Physio notes state decreased mobility and increased tremor Day 3:  reviewed by Consultant and Medical Officer. Noted decreasing mobility and worsening of tremor MO calls pharmacy and requests review of medications Notes state: “review of medications, discuss with GP about meds, ?Neurologist involved in patient care; ?Increase dose and add medications ”

Ian’s Story Day 3: After phone call from MO, a pharmacist reviews patient.  Patient poor historian; pharmacist phones wife and uses Webster pack to obtain BPMH  When comparing BPMH to med chart, multiple discrepancies identified: Omitted levodopa/carbidopa CR 200/50mg nocte Omitted mirtazapine 30mg nocte Omitted pregabalin 25mg nocte Omitted quetiapine 50mg nocte Omitted amlodipine 10mg nocte Incorrect timing for patients other Parkinson’s medication  MO informed  correct meds and times charted 56 hours post admission  Mobility and condition improved; patient discharged

Event Analysis  Incident reported by pharmacist doing BPMH  Decision made to complete EA  Concise EA completed by team: Chief Pharmacist Clinical Pharmacist Medical Officer Safety and Quality Unit Project Officer

Event Analysis  Event Details Patient details Narrative of what happened Medications involved  Classification of extent of harm to the patient

Event Analysis Contributing Factors  Education and Training MO unable to collect BPMH accurately despite having Webster Pack. Did not know how to decipher medication details from Webster Pack Missed the 10pm “slot”  Staffing Patient initially admitted to AMU for 24 hrs before transfer to medical ward. AMU does not have allocated clinical pharmacist  Med Rec not completed within 24 hrs. Gen Med pharmacist on leave; another pharmacist went to see pt when requested by Dr  Patient Patient poor historian Primary Contributing Factors  Education and Training

Event Analysis  Measurable actions/changes for hospital

Conclusion  Event analysis beneficial as a “fact finding” tool Used to seek and investigate patient safety problems to identify if there are problems with the SOP and to identify cause and effect Multidisciplinary approach Less labour/resource intensive than RCA Measurable actions and changes to implement to improve patient safety