1. Medication Reconciliation A Saskatoon Health Region Initiative

2. 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
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)

3. Medication Reconciliation can:
Prevent omission of an at-home medication
Match in-house dose, frequency and route with at-home dose
Assure medications follow the patient from one care site to another

4. Why? Recent media attention and legal cases
Concern over patient safety is growing, both among the Canadian public and among health care providers
% of patients in acute care hospitals experienced one or more adverse events
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
ADEs occur with disturbing frequency & 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 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.]
The Canadian Adverse Events Study (May 2004)
7.5% of patients admitted to acute care hospitals in Canada in 2000 experienced one or more AEs
36.9% of those patients were judged to have highly preventable AEs.
1521 additional hospital days associated with AEs
Therefore, in the almost 2.5 million annual hospital admissions in Canada, about 185,000 are associated with an AE and close to 70,000 of these are potentially preventable.
[Baker GR. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170: ]
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: ]

5. 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 new Canadian Council on Health Services Accreditation Standard
Senior Leadership has endorsed Medication Reconciliation as a Regional Project of high priority
Reduces work and re-work!
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].

6. Potential Impact
Implementation of medication reconciliation along with other interventions decreased the rate of medication errors by 70% and adverse drug events by 15%, over a seven month period.[i]
Implementation in a surgical population reduced potential adverse drug events by 80% within three months of implementation.[ii]
[i] Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care 2004;13(1):53-59
[ii] Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm 2003;60:

7. Potential Impact
There was a five fold reduction (1.75% to 0.35%) in the number of medication errors upon admission with implementation of medication reconciliation upon admission.[i]
For those with no missing medications, drug related problems after discharge were reduced from 85% with original prescription process, to 35%.[ii]
[i] Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. J Qual Patient Saf 2005;31(7):
[ii] Poole DL, Chainakul MP, Graham L. Medication reconciliation: A hospital necessity in promoting a safe hospital discharge. J Healthc Qual (NAHQ) 2006 May/June

8. Potential Impact: The Time Crunch!!
Nursing Time at admission was reduced by 20 minutes per client, and pharmacist time at discharge was reduced by over 40 minutes per client.[i]
[i] Rozich JD, Resar RK, et al. Standardization as a mechanism to improve safety in healthcare: impact of sliding scale insulin protocol and reconciliation of medications initiatives. Jt Comm J Qual Patient Saf 2004;30(1):5-14

9. Origins of Medication Reconciliation
The Institute for Healthcare Improvement (IHI) introduced the 100K Lives campaign in 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
On April 12, 2005, the Canadian campaign, Safer Healthcare Now! was created. SHR is a registered member.
IHI’s Aim: Improve patient safety through implementation of six targeted strategies proven to prevent adverse events
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

10. SHR Medication Reconciliation Initiative
Ultimate goal:
Prevent adverse drug events by implementing medication reconciliation
How?
Use the Model for Improvement
Use Plan, Do, Study, Act (PDSA) cycles to test form and process
Make small changes, test, obtain feedback, revise and re-test.
Start with the Admission process

11. Pilot Sites & Champions
RUH Pediatrics
RUH Surgery 5000
SPH 6th Medicine
SCH Gynecology 4300 (PAC)
St. Elizabeth’s Hospital (Humboldt)

12. Stories
Patient on chlorpropamide in hospital. Discharged on chlorpromazine (transcription error). Patient taking chlorpromazine at home. Patient re-admitted twice before error in transcription identified.
Patient experiencing bradycardia & hypotension during admission. Double the dose of beta-blocker inadvertently ordered on admission.
Patient admitted to medical ward. Three days later found seizing in room. Patient was on phenytoin at home and it was not ordered on admission (staff unaware patient was taking at home).
Patient admitted to ward via ER. Numerous medications ordered on admission including 2 beta-blockers. Pharmacist initiated medication history identified that patient had long since discontinued several of the medications ordered on admission (e.g., amiodarone, metoprolol). EMT brought all medication in patient’s medicine cabinet even though many had been discontinued. All medications were ordered on admission.

13. SHR Baseline Data Undocumented Intentional Discrepancies:
1.32 / patient
Unintentional Discrepancies:
1.28 / patient
Medication Reconciliation Success Index:
67.9%
We are currently tracking 3 measurements to determine the success of the form and process. 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
Medication reconciliation success index: 67.9%
This measure helps to assess the effectiveness of changes over time. As we improve, the success index should increase. SHR goal: increase by 75% in 12 months on pilot sites
= # no discrepancies + # documented intentional discrepancies / # no discrepancies + total # of all discrepancies x 100

14. SHR Form and Process A formal process of:
Obtaining a 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.

15. Medication Reconciliation
Form and Process

16. 1. Addressograph 2. Allergies 3. Height & Weight ISMP standard
ISMP standard. Required information for pharmacist to process order.
3. Height &
Weight
ISMP standard
ISMP = Institute for Safe Medication Practices

17. 4. List all medications
patient was taking
PTA, including name, dose, frequency, route.
[MD, RN/LPN/RPN, BSP]
Do not re-write meds on admitting databases [use stamp].
5. Time / date of last dose.

18. 7. MD to indicate if med is to continue, stop, or change
7. MD to indicate if med is to continue, stop, or change. Comments can also be added.
8. MD signs / dates order. Once this occurs no further changes can be made to order section. RN crosses out blank lines.
6. Name of person who obtained history.

19. 11. Document any comments, concerns, or follow-up required.
10. A form is completed for all patients even if on no medications prior to admission.
11. Document any comments, concerns, or follow-up required.
9. RN/LPN/RPN
initials when orders are processed, faxed, and MAR’d.

20. Other:
If PAC patient: double check info on day of surgery.
Source of information.
Disposition of patient’s medications.
Check if information continues on second page.
Page number

21. Page 2 available,
when necessary

22. Patient / caregiver, etc. provide new information at later date.
Take new form & check ‘addendum’ if additional information becomes available after the original form has been signed by the physician.
Patient / caregiver, etc.
provide new information
at later date.
Document the changes only.

23. Stamp
The presenter should check with the team lead for the area prior to the presentation to determine what process has been worked out for use of the stamp. This information should be shared with staff during the presentation (e.g., location of stamps, who will stamp ? RN ? Clerk)
- Can use stamp or hand-write if stamp unavailable.

24. Complete & Accurate Medication List
Essential component of safe and effective patient care.
Essential component of medication reconciliation.
List should include information on all medications the patient was taking prior to admission, including prescription, non-prescription, herbal products, and supplements.

25. Questions to Obtain Admission Medication List
Do you have any allergies to medication? Describe the reaction.
What medication were you taking prior to admission?
Did a doctor change the dose or stop any of your medication recently?
Have you changed the dose or stopped any of your medication recently?
Have you recently started any medications?
Do you have any allergies to medication? Describe the reaction.
What medication were you taking prior to admission?
Ask about all medications: prescription, non-prescription, herbs, vitamins or supplements, teas, traditional remedies, anything from a herbalist or health store.
Remember to ask about creams, drops, inhalers, sprays, patches, injections, samples, investigational or study drugs.
Include medication name, dose, frequency, route, & time of last dose.
Did a doctor change the dose or stop any of your medication recently?
Have you changed the dose or stopped any of your medication recently?
Have you recently started any medications?

26. Questions to Obtain Admission Medication List
Have any of your medications been causing side effects?
When you feel better, do you sometimes stop taking your medication?
Sometimes if you feel worse when you take your medication, do you stop taking it?
Are the pills in the bottle the same as what is on the label?
Have you changed your daily routine to accommodate your medication schedule?
When possible, use multiple sources of information: medication labels, family, caregivers, community pharmacy, family practitioner.
Material to assist:
Tips on back of order form
Laminated card available

27. Vision for the Future Admission Form linked to Drug Plan Information
IT solutions - Transfer and Discharge piece
Working on various strategies to make the process safer and simpler
Admission Form linked to Drug Plan Information
Working with Sask. Health to link Pharmaceutical Information Program (PIP) with a provincial medication reconciliation form
PIP profile accessed on admission and printed
Printed format to serve as basis for admission orders
HCP reviews medications listed with patient
MD decides to continue, stop, or change
Additional blank lines provided to add medications the patient was taking at home but were not captured with PIP.
IT solutions - Transfer and Discharge piece
Modified Pharmacy patient profile printed on transfer and discharge
Profile lists current medications. Area for physician to decide if medication is continued, changed, or discontinued.
Serves as the discharge medication prescription
Advantages: saves time, eliminates transcription errors, no orders are missed
Working on:
Approval from Sk College of Pharmacists
Strategies for printing - Remote printing? Designated phone line?

28. DRAFT

29. The Train Has Left The Station...Are YOU On It?
Medication reconciliation fits perfectly with SHR’s culture of safety and optimal patient care
Medication reconciliation has already shown reduced medication discrepancies on pilot sites within SHR
Need to add explanation down here so that anyone can explain this.
Undocumented Intentional Discrepancies:
Baseline: 1.32 / patient; PDSA cycle #3: 1.47 / patient
Unintentional Discrepancies:
Baseline: 1.28 / patient; PDSA cycle #3: 0.68 / patient…we are on target here for reducing the number of unintentional discrepancies. We still have work to do. Medication Reconciliation Success Index:
Baseline: 67.9%; PDSA cycle #3: 77.6%

30. Results: Run Charts of Key Measures
Baseline
PDSA #2
PDSA #3

31. Results: Run Charts of Key Measures
PDSA #2
PDSA #3
Baseline
Improving! Provide enhancements to facilitate medication history.

32. Results: Run Charts of Key Measures
Baseline
PDSA #2
PDSA #3

33. The Train Has Left The Station...Are YOU On It?
Medication reconciliation will save time for nurses, physicians, and pharmacists
HCPs already take a medication history: now we are doing it on one form and it will be easier to find
Future computerization will simplify the process even more (e.g. drug plan histories will appear on the admission form)
Medication reconciliation will save time for nurses, physicians, and pharmacists
Less time spent clarifying medication orders
Less time spent documenting medication histories
Remember this section is to do the following:
-relative advantages of the system (above – save time…what’s in it for them and for the patient)
-compatibility with current system (IT changes will make it better)
-Simplicity of the change and transition (already doing this now it is on one page)
-Testability of change (have done pdsa for past six months to make sure changes are working)
-ability to observe the change and see its impact (data provided)

34. The Train Has Left The Station...Are YOU On It?
HCPs will know that a medication change is intentional (rather than wonder if there was a transcription error or a missed order), and be able to advise the patient and family members accordingly
It will be easy to find the at-home medication list in order to reconcile on discharge as all preadmission medications will be on the new admission form

35. The Train Has Left The Station...Are YOU On It?
Transcription errors will be eliminated on transfer and discharge using current computer capabilities
A clear discharge medication list will be available for patients, pharmacists and physicians
Outcomes from the changes are being monitored (PDSA cycles), and improvements are already evident

36. Questions?