1. Medication Reconciliation and Reducing Adverse Drug Events
Regional Learning & Action Network Meetings 2017

2. Importance of Getting Medication Management Right
“Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system.” - The Institute of Medicine (IOM), 2007
The Institute of Academy of Sciences. Informing the future: Critical issues in health. Fourth edition, page 13.

3. Building the Case 1999 Institute of Medicine (IOM) report
To Err is Human
44,000–98,000 people die each year as a direct result of medical errors
2006 IOM report
Preventing Medication Errors
400,000 preventable drug-related injuries occur in U.S. hospitals each year, each costing about $8,750
Journal for Healthcare Quality
Vol. 36, No. 6, pp. 58–68 C National Association for Healthcare Quality

4. Building the Case (cont.)
2010 U.S, Office of Inspector General
44 percent hospital adverse events were preventable
The most common preventable adverse events were related to medications (42 percent)
Journal for Healthcare Quality
Vol. 36, No. 6, pp. 58–68 C National Association for Healthcare Quality

5. Building the Case (cont.)
2014 Annals of Pharmacotherapy
28 to 60 percent of ADEs leading to hospital admission are preventable
2001 Pharmacoepidemiology and Drug Safety
Emergency hospitalizations for recognized ADEs in older adults most often result from warfarin, insulin, antiplatelet and oral hypoglycemic agents
2002 Annals of Pharmacotherapy
Patients rehospitalized within 30 days have more complex medication regimens
Willson MN, et al. Medication regimen complexity and hospital readmission for an adverse drug event. Ann Pharmacotherapy Jan;48(1):26-32.
Jha AK, et al. Identifying hospital admissions due to adverse drug events using a computer-based monitor. Pharmacoepidemiology Drug Saf Mar-Apr;10(2):113-9.
McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacotherapy Sep;36(9):

6. Adverse Drug Events (ADEs)

7. Medication Safety Definitions
Term
Definition
Example
Adverse Drug Event (ADE)
INJURY resulting from medical intervention related to a drug. Most are preventable.
Bleeding from Coumadin overdose.
Adverse Drug Reaction (ADR)
Harm directly caused by a drug at usual doses. Causal link between the drug and the harm.
Allergic reaction.
Medication Error
Inappropriate use of a drug that may or may not cause harm. Preventable.
Patient receives wrong medication.
Potential Adverse Drug Event (pADE)
Medication error that could potentially lead to ADE, stopped before harm can occur.
Patient has an order for a medication to which he/she is allergic, order changed before patient takes the medication.

8. ADEs, Hospital Utilization and 30 Day Readmissions

9. Medication Related Problems (MRP)
Practitioners
Patient
Drug
Adverse reactions
Medication reconciliation not done
Patient sent home with an incorrect list
Interaction from multi-prescribers (Rx, OTC, Herbal, Foods, etc.) not assessed Drug/Dose
Misinformation-EMR and Med list does not match
Provider does not know if script filled
Cost
Access
Availability
Therapeutic Drug Monitoring
Clinical status changes
Compliance & Adherence (pt. fails teach back)
Prescribing error
Dispensing error
Activity
Age specific dosing adjustment
Substance Abuse & Misuse
Lack of engagement of patient and family in D/C plan
Lack of communication during transitions in care
Duplicate therapy
Pharmacogenomics

10. Medication Management
Reconcile medications on admission with input from patient and family at all levels of care (Home, Home Health, SNF, NH, Hospice, Assisted living etc..)
Resolve discrepancies such as omissions, duplications, adjustments, deletions, and additions to the medication list during hospital stay
Provide the most current list of medications to the next care provider
Assess patient’s ability or inability to name medications, their purpose and how and when to take the medication and know any special precautions listed in the record

11. Medication Management
Alert and educate family/caregiver if patient is unable to name medications and purpose, Discuss patient needs with next care provider set up planned follow-up
Refer patients with more than five medications or more than two medication changes during hospitalization for pharmacy/ medication management follow-up
Discuss opting out of scheduled refills and automatic refills until medications are reconciled with pharmacist

12. Medication Management (cont.)
Refer patients with complex medications to the pharmacy for outpatient education, medication review, follow-up calls and in home visits
OTHER Interventions??? l

13. Quality Measures (7) Reduction in statewide Adverse Drug Events
Reduction in statewide Readmissions for beneficiaries at High Risk* for an adverse drug event related to
Anticoagulant medications;
Diabetic medications;
Opioid medications
Reduction in statewide Hospital Utilization (Admissions, ER or Observations) for beneficiaries at High Risk* for an adverse drug event related to
*Taking three medications plus an anticoagulant , diabetic or
Opioid medication. Can be counted for each high risk medication

18. Integrating Medication Reconciliation and ADE Prevention
Medication reconciliation at each new encounter
Reduce the number of potentially inappropriate medications
Decrease the risk of an ADE through better communication and patient/family education/engagement/empowerment
Focus on the three high risk medications:
Opioid, Anticoagulant, and Diabetic

19. State opioid prescribing rates vary up to 3-fold

20. Factors driving overuse of opioids
Knowledge gaps:
Overestimation of effectiveness for chronic pain
Underestimation of opioid use disorder and overdose risks
Lack of familiarity with non-opioid treatments
Insufficient access to non-opioid treatments
Patient requests for opioids
Time pressure; It takes time
to explain why opioids are not the best treatment
to arrange non-opioid treatment

21. Opioid Medication Patient Education
Fact sheets-What You need to Know
Posters
PowerPoint Presentations
Brochures
Pocket cards
Checklist

22. Anticoagulation Medication Patient Education
Excessive anticoagulation with warfarin
Increase “in control” INR
Testing at least every 30 days
Anticoagulation Clinic UC San Diego Health
Anticoagulation Centers of Excellence
American Heart Association

23. Diabetic Medication Patient Education
Hypoglycemia in persons receiving insulin
Increase “in control” A1c
Testing every three months
Mississippi Diabetes Association |
American Diabetes Association |
Diabetes Forecast-Type 2 Diabetic Medications |

26. Contact Information
Join the community coalition near you and serve on the
Medication Safety workgroup
Mary Helen Conner, PhD, MPH, BSN, RN, MCHES
Quality Improvement Advisor
ext. 219