1. How Medication Reconciliation Supports Patient Safety 15 September 2007
Jane Richardson, BSP, PhD, FCSHP
Coordinator, Clinical Pharmacy Services
Team Lead, SCH Med Rec Pilot Site

2. Objectives
To define Medication Reconciliation & describe why it’s important.
To outline our initial experience with admission Medication Reconciliation within the Saskatoon Health Region (SHR).
To describe early use of the Pharmaceutical Information Program (PIP) auto-populated Medication Reconciliation form in SHR Emergency Departments.

3. Medication Reconciliation – what is it?
A formal process of:
Obtaining a complete and accurate list of each patient’s current home medications (name, dosage, frequency, route)
Comparing the physician’s admission, transfer, and/or discharge orders to that list
Bringing discrepancies to the attention of the prescriber and ensuring changes are made to the orders, when appropriate
Reference: IHI, Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation)

4. Institute for Healthcare Improvement
The Institute for Healthcare Improvement introduced the 100K Lives campaign, December 2004, to challenge health care providers to join a national effort to make health care safer & more effective & ensure hospitals achieve the best possible outcomes for all patients
How? Implement six targeted strategies proven to prevent adverse events
The initiative captured the attention of Canadian care providers, hospital administrators & others committed to improving patient safety.
On April 12, 2005, the Canadian campaign, Safer Healthcare Now! was created.

5. IHI / Safer Healthcare Now! Initiatives
Improved care for AMI
Prevent surgical site infections
Prevent central line infections
Prevent ventilator associated pneumonia
Deploy rapid response teams
Prevent adverse drug events: Medication reconciliation

6. Why Medication Reconciliation?
% of patients, in acute care hospitals, have experienced one or more adverse events
Adverse drug events are a leading cause of injury to hospitalized patients
Greater than 50% of all hospital medication errors occur at the interfaces of care
Admission to hospital
Transfer from one nursing unit to another
Transfer to step-down care
Discharge from hospital
Transition points are areas of great vulnerability for our patients
Greater than 50% of all hospital medication errors occur at the interfaces of care.
Admission to hospital, Transfer from 1 nursing unit to another, Transfer to step-down care, Discharge from hospital [Rozich JD. Medication safety: One organization’s approach to the challenge. JCOM. 2001;8(10):27-34.]

7. Why Medication Reconciliation?
Frequency of medication discrepancies on a general medicine clinical teaching unit
53.6% of patients had at least one unintended discrepancy
38.6% of the discrepancies were judged to have the potential to cause moderate – severe discomfort or clinical deterioration
Most common error was an omission of a regularly used medication (46.4%)
Arch Intern Med, 2005
Patients were on at least 4 regular prescription medications
Patients could not be admitted from an extended care facility
A recent Canadian study examined the frequency of medication discrepancies on a general medicine clinical teaching unit.
53.6% of patients had at least 1 unintended discrepancy
38.6% of these discrepancies were judged to have the potential to cause moderate – severe discomfort or clinical deterioration
Most common error was an omission of a regularly used medication (46.4%)
[Cornish PL. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165: ]

8. SCH Patient: MP
76 y.o. woman attending GDH admitted to CCU with bradycardia, then returned to GDH after receiving a pacemaker
CCU admission medication orders based on faxed hand-written list from community pharmacy
Errors:
Lescol 20mg written as Losec 20mg (Rx error)
Tramacet recorded as Tagamet (MD error)
On warfarin for AF: not ordered on admission or restarted on discharge
Sertraline & metformin put on hold in hospital but not reordered on discharge
Community pharmacist had no idea what this woman should or shouldn’t have in her blister pack

9. Medication Reconciliation – the solution?
Medication Reconciliation can:
Prevent omission of an at-home medication
Match in-house dose, frequency, and route with at-home usage
Ensure medications follow the patient from one care site to another
Key point: creating the most complete and accurate list possible of all home medication for each patient.

10. Why Now? It’s the right thing to do……..
Culture of safety: reduce medication errors & potential for patient harm
Key component of seamless care strategies
Saves time for physicians, nurses, and pharmacists in the long-term
Medication Reconciliation is a Canadian Council on Health Services Accreditation Standard (ROP)
In the SHR, Senior Leadership has endorsed Medication Reconciliation as a Regional Project of high priority
Saves time for physicians, nurses, and pharmacists in the long-term [Rozich JD, Resar RK. Medication safety: One organization’s approach to the challenge. JCOM 2001;8(10):27-34].
A Required Organizational Practices (ROP) is an essential practice that Canadian Council on Health Services Accreditation (CCHSA) has determined, based on evidence, what an organization must have in place to enhance patient/client safety and minimize risk. These goals and practices were first approved by the CCHSA Board in 2004, and came into effect in January 2005.

11. SHR Form and Process A formal process of:
Obtaining ONE complete and accurate list of each patient’s current home medications (name, dosage, frequency, route)
Using the information obtained to write the admission orders
Referring back to the information obtained to write transfer and discharge orders
Our approach incorporates the two primary concepts of obtaining accurate medication lists and preventing discrepancies by using a process that combines medication histories & physician orders on one form.
The reason for this is that the Preadmission Medication List Physician Order Form serves a dual purpose:
(1) area to document the patient’s medications they were taking prior to admission (not to be duplicated in the RN database)
(2) serves as the admission orders for that patient. This should eliminate any transcription errors and save health care professionals time by documenting in 1 section.

12. Medication Reconciliation
SHR Manual
Medication Reconciliation
Form and Process

13. Medication Reconciliation
Form, page 2

14. Measuring Progress: Discrepancies
Undocumented intentional discrepancy:
physician made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented
Unintentional discrepancy:
physician unintentionally changed, added or omitted a medication the patient was taking prior to admission
Goal:
reduce number of discrepancies by 75%

15. SHR Baseline Data (5 Pilot Sites)
Undocumented Intentional Discrepancies:
1.32 / patient
Goal: 0.33 / patient
Unintentional Discrepancies:
1.28 / patient
Goal: 0.32 / patient
Baseline data was collected on each of the five pilot sites and the collated results are reported on the slide.
Undocumented intentional discrepancies: 1.32 / patient
An undocumented intentional discrepancy is one in which the physician has made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented. SHR goal: reduce by 75% in 12 months on pilot sites
= # undocumented intentional discrepancies / # patients
Unintentional discrepancies: 1.28 / patient
An unintentional discrepancy is one in which the physician unintentionally changed, added, or omitted a medication the patient was taking prior to admission. SHR goal: reduce by 75% in 12 months on pilot sites
= # unintentional discrepancies / # patients

16. Are we making a difference?
Baseline
National: 1.1
Revise
form
PDSA 2
National: 0.6
PDSA 3
March 2007 SHR Data = 0.25
1 yr data
check
PDSA 4
Education
PDSA 1
survey

17. Are we making a difference?
Revise
form
PDSA 2
National: 1.2
PDSA 3
Baseline
PDSA 4
1 yr data
check
Education
March 2007 SHR = 0.75
National: 0.65
PDSA 1
survey

18. Comments on the Manual Form
It’s a blank form!
All medication information will have to be written in:
Will need to get the information from someone or somewhere.
How accurate is that information?
Potential for transcription errors when recording the medication history.
We need to get the medication history right for the rest of the process to work

19. Medication Reconciliation Form
The Next Step
Using PIP to Generate
an Admission
Medication Reconciliation Form

20. PIP Auto-populated
Medication
Reconciliation
Form

21. Has it made a difference?
SCH Emergency Admissions to General Medicine:
Undocumented Intentional Discrepancies
SHR Goal: 0.33 / patient
April 2007 (Manual Form): 0.1
September 2007 (PIP Form): 0.2
Unintentional Discrepancies
SHR Goal: 0.32 / patient
April 2007 (Manual Form): 3.1
September 2007 (PIP Form): 1.3

22. Comments on the PIP Auto-populated Form
Gives medication name, strength, most recent fill date & prescriber’s name
A better starting point than a blank page, especially if a patient or caregiver cannot provide information.
Dose & interval still need to be clarified (& may be different than what was on the original prescription)
Still need to ask about medications not recorded on PIP
Avoids name & strength transcription errors for auto-populated medications

23. Conclusions Medication Reconciliation does decrease medication errors
The Pharmaceutical Information Program auto-populated history and admission order form is a valuable tool for this initiative
Through collaboration we are advancing patient safety in Saskatchewan