1. Medication Reconciliation in Continuing Care
Getting It Right Together
Creating a Culture of Safety
September 8, 2008
Dr. Paula Creighton MD, FRCP(C)
Geriatric Medicine Specialist
Cape Breton District Health Authority

2. Outline Understand why Medication Reconciliation
is getting so much attention through:
Understanding how adverse drug events (ADEs) commonly occur
Identify practical steps that can reduce the risk of ADEs in practice
Identify key features of a safer system
September 2008
Dr. Paula Creighton

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Dr. Paula Creighton

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Dr. Paula Creighton

5. Definition Adverse Event
UNINTENDED act or event during care
May result in potential harm
Harm = increase length of stay
= temporary/permanent disability
= death
September 2008
Dr. Paula Creighton

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Dr. Paula Creighton

7. How ADEs occur?
Increase range of medicines to treat or prevent disease
Multiple co-morbid conditions
Age-related changes physiology
Tsilimingras, Rosen, &. Berlowitz 2003.
Canadian Patient Safety (CPSI) Institute 2006
September 2008
Dr. Paula Creighton

8. How ADEs occur? Multiple health care practitioners
Frequent visit to hospital setting (hospitalization, procedures, tests)
Adherence problems
Tsilimingras, Rosen, &. Berlowitz 2003.
Canadian Patient Safety (CPSI) Institute 2006
September 2008
Dr. Paula Creighton

9. How ADEs occur? OTC medication use
Impaired vision, dexterity, literacy
Tsilimingras, Rosen, &. Berlowitz 2003.
Canadian Patient Safety (CPSI) Institute 2006
September 2008
Dr. Paula Creighton

10. When ADEs occur? Entry and exit points of clinical encounters
Cornish P. et al Arch Intern Med 2005:165;
September 2008
Dr. Paula Creighton

11. Traditional Medication History
Labels
Lists
Verbal (open ended inquiry)
Someone else has/will complete
September 2008
Dr. Paula Creighton

12. Limitations to Traditional Medication History
Discrepancies:
Unintentional
Undocumented Intentional
September 2008
Dr. Paula Creighton

13. Unintentional Discrepancies
Over-the-counter medications
Shared prescriptions
Labels “as directed”
Prescription change without script
Samples
September 2008
Dr. Paula Creighton

14. Undocumented Intentional Discrepancies
What changed and why?
Convey a clear understanding of desired outcomes to therapy.
Written communication with patient/family and pharmacist
September 2008
Dr. Paula Creighton

15. Get Involved
safer healthcare
Now!
September 2008
Dr. Paula Creighton

16. Key Features toward a Safer System
Change
September 2008
Dr. Paula Creighton

17. Key for a Safer System …If you always do what you have always done;
Doing our jobs differently…
…If you always do what you have always done;
You always will get what you always got
September 2008
Dr. Paula Creighton

18. Practical steps to reduce risk of ADEs
“To prescribe according to best evidence from scientific research and to be mindful of the precepts of patient autonomy”
Holland R, Wright D. Medication Review for Older Adults. Geriatrics and Aging March 2006, Vol 9. No.3.
September 2008
Dr. Paula Creighton

19. Practical steps to reduce risk of ADEs
When might it be best to withhold or discontinue medications that are otherwise appropriate on the basis of guidelines?
September 2008
Dr. Paula Creighton

20. Practical steps to reduce risk of ADEs
Consider life expectancy
Goals of care and quality of life defined by patient/family
Potential benefit & risk of medications
September 2008
Dr. Paula Creighton

21. Practical steps to reduce risk of ADEs
Start low,
Go slow,
Or don’t start at all!
September 2008
Dr. Paula Creighton

22. Practical steps to reduce risk of ADEs
Partnering with Patients
“Nothing about me, without me”
(author unknown)
September 2008
Dr. Paula Creighton

23. Medication Reconciliation
Partnering with Patients
patient/family interview
September 2008
Dr. Paula Creighton

24. Practical steps to reduce risk of ADEs
Humans require formal cues/processes to stay on track reliably
Reliable work processes account for the known imperfections of humans
Adapted from PSO Training Course (IHI) 2004
September 2008
Dr. Paula Creighton

25. Medication Reconciliation
MEDICATION RECONCILIATION: include on list below Over the counter products, Samples, Shared pills
Drug Name
Drug Strength
When Taken
Indicate if:
-New
-Change from label
-Effects from new and change
Morning
Noon
Evening
Bedtime 1 2 3 4 5 6
September 2008
Dr. Paula Creighton

26. Threats for Change toward a Safer System
Power Gradient
Fear
(Mis)-Perception “touchy, feely” initiatives
September 2008
Dr. Paula Creighton

27. Key for Change toward a Safer System
Self audit:
More mirrors and fewer windows
September 2008
Dr. Paula Creighton

28. Self Audit
"One of the major impediments to convincing people of the prevalence and seriousness of cognitive error is the faith they have in their own thinking abilities"
Croskerry, P. The Science of Human Factors in Healthcare, QHN, October 2003
September 2008
Dr. Paula Creighton

29. Key for Change toward a Safer System
“ Many little people
Doing many little things
In many little places
Can change the world.”
(Chinese Proverb; author unknown)
Susan Sheridan, Chair, Patients for Patient Safety Strand, WHO World Alliance for Patient Safety; Co-Founder, Consumers Advancing Patient Safety, Eagle, Idaho
September 2008
Dr. Paula Creighton

30. Get Involved
safer healthcare
Now!
September 2008
Dr. Paula Creighton