1. Jay Ginsberg, MD Network 1 MAC Representative

2. Why Reconcile Medications? Medication reconciliation is an effective process to reduce errors and harm associated with loss of medication information, as patients transfer among community-based and hospital providers. It may prevent up to 70% of all potential errors and 15% of all adverse drug events. -Joint Commission (2006)

3. Definition of Medication Error A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. -National Coordinating Council for Medication Error Reporting and Prevention

4. A Great American Philosopher If the world was perfect, it wouldn't be. Yogi Berra Yogi Berra We don’t want to take this view on Medication Reconciliation!

5. Who Thinks Med Reconciliation is Important? Institute of Medicine (1999) Joint Commission (2006) CMS has funded projects to evaluate best practices in medication reconciliation NQF Has sponsored studies of medication reconciliation

6. Medication Statistics Medication Related Problems are implicated in 16.1% of internal medicine ward hospital admissions. Nelson, KM; Talbert, RL. Drug-related hospital admissions. Pharmacotherapy. 1996;16:701–707 58.9% of admissions could definitely or possibly be avoided. Nelson, KM; Talbert, RL. Drug-related hospital admissions. Pharmacotherapy. 1996;16:701–707 Once admitted to the internal medicine ward, greater than 18% of patient deaths can be attributed to one or more drugs Ebbesen, J; Buajordet, I; Erikssen, J; Brors, O; Hilberg, J; Svaar, H; Sandvik, L. Drug-related deaths in a department of internal medicine. Arch Intern Med. 2001;161:2317–2323

7. Medication Statistics Adverse drug events contribute to over 100,000 deaths annually Lazarou, J; Pomeranz, BH; Corey, PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200–1205 25% of ambulatory patients report experiencing at least one adverse drug event Gandhi, TK et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–1564 The economic burden of MRP on the healthcare system is estimated to be in excess of $177 billion Ernst, FR; Grizzle, AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc(wash). 2001;41:192–9

8. Dialysis Statistics The average dialysis patient takes 6 to 10 medicines a day. Curtin RB, Svarstad BL, Keller TH. Hemodialysis patients’ noncompliance with oral medications. ANNA J. 1999;26:307-316. Kaplan B, Mason NA, Shimp LA, Ascione FJ. Chronic hemodialysis patients, part I: Characterization and drug-related problems. Ann Pharmacother. 1994;28:316-319. Szeto et. Al. (Clinical nephrology 2006 vol. 66:4, pp. 256- 262) On a-verage, each patient required 4.7 ±1.8 type of medications Average was 10.0 ± 4.9 tablets per day 15.0% needed at least 7 types of medication 12.4% had to take more than 15 tablets each day

9. Is This Important to Dialysis Facilities? Informal Survey Conducted by MAC

10. Is This Important to Dialysis Facilities? But: PubMed search revealed only one article on medication reconciliation in dialysis patients

11. Medication reconciliation in hemodialysis patients; Ledger S, Choma GLedger SChoma G Evaluation of impact of medication reconciliation and optimization at the time of patient transfer from an in- centre dialysis unit to a satellite dialysis unit 78.8% of patients had at least one unintended medication variance The majority of unintended variances (56%) were caused by the physician/nurse practitioner omitting an order for medication that the patient was taking. “In this small study, medication reconciliation was effective at identifying and rectifying medication errors and optimizing pharmacotherapy at the time of transfer from an in-centre hemodialysis to a satellite dialysis unit.”

12. Health & Safety Survey Project 2006 Survey about Safety Concerns Invitations to participate in an anonymous survey sent to 3,587 patients drawn from a representative national patient sample Network #1 implemented the patient selection and coordinated survey mailing and responses Surveys completed by 1,762 patients

13. Health & Safety Survey Project Dialysis Health Professionals Invitations to participate in an anonymous web-based survey widely distributed by RPA, Networks, Professional Meetings Web-based Surveys completed by 649 professionals

14. Patient Response

15. 40% patients report that they discuss their meds with their doctor only “sometimes.”

16. Health & Safety Survey Project Professional Survey: Past 3 months 43% professionals report 1 or more instances of patient given the wrong medicine or medicine at wrong time 63% report patients fail to receive 1 of their meds at times 37% report that a patient is given wrong dose of a medication at least once Overall 77% staff indicate a patient had a medication omission or error in past 3 months

17. What to do? Considering the large number of medications taken by the average dialysis patient the problem of medication errors is a huge one. The practice of Medication Reconciliation offers the opportunity to reduce medication errors and thereby improve patient care.

18. When is an Accurate Medication List Important “Handoff” from hospital to Chronic Unit Patients’ medications are changed in the dialysis unit Medications are changed by an outside physician In a disaster

19. Components of Medication Reconciliation Collecting an accurate medication history Making certain the medications and the doses are appropriate Educating the Patients about the Medications Documenting each change that is made along the way

20. Collecting an accurate medication history What has been ordered for the patient? What is the patient really taking?

21. Making certain the medications and the doses are appropriate Need list of all medications Need accurate information of the patient’s co- morbidities

22. Educating the Patients about Medications A 2007 study confirms that medication knowledge of hemodialysis patients was extremely poor regarding the name, indication and dosage regimen of their medications BS Sathvik, Seema Mangasuli, MG Narahari, KC Gurudev, G Parthasarathi Indian Journal of Pharmaceutical Sciences 2007 69:2 232-239

23. Documenting each change that is made along the way Each “handoff” should include a reconciliation Provide health care professionals at each visit by the patient with an accurate medication list

24. Current Practices Many facilities have computerized medication lists How often are they updated? Patients are asked to list their medications How often are they asked if they understand why they are asked to take the medications? Patients may bring in their pills Are they really taking all those pills?

25. A Great American Philosopher If you don't know where you are going, you might wind up someplace else. Yogi Berra Yogi Berra

26. Ways Medication Reconciliation Might Be Improved Examples of possible changes in process Standardized process for checking medications in a unit Med checking on a given day each month Standardized handoff after hospitalization Part of accepting a patient back into the unit might be a requirement that a copy of the med list be faxed Review of medication changes after each visit to a provider The facility might send a form with the patient to be filled out by the physician’s office staff with any medication changes

27. Ways Medication Reconciliation Might Be Improved Accountability Medication Coordinator in a facility Primary nursing with the requirement that meds be reconciled Education of patients about medications Printed materials Web sites Contests at a facility about common medications

28. Ways Medication Reconciliation Might Be Improved Since facilities vary so much, no answer is appropriate for all Facilities should be encouraged to do Quality Assessment and Performance Improvement Projects to improve Medication Reconciliation Medical Advisory Council of the Forum is attempting to develop tools that can be offered to facilities to help them develop QAPI projects

29. Sample Tool (Developed by Network 11, Modified by MAC)

30. TASKS RESPONSIBLE TEAM MEMBER START DATE ESTIMATED COMPLETION DATE ACTUAL COMPLETION DATE COMMENTS (STATUS, OUTCOMES, EVALUATION, ETC.) 1. 2. 3. 4. 5. COMMENTS:

31. A Great American Philosopher In theory there is no difference between theory and practice. In practice there is. Yogi Berra Yogi Berra

32. Pitfalls Assumption that because the medications have been reconciled the patient is really taking them Changes in formulations A brand change of a medication might result in different absorption that reconciliation would not pick up The medication list is only accurate if The patient understands what she is taking The person taking the information is knowledgeable and thorough

33. Medication Reconciliation Summary 1. Medication Reconciliation is important in providing quality patient care 2. In dialysis units Medication Reconciliation is particularly important due to the complexity of the patients 3. Components of Medication Reconciliation include: Collecting an accurate medication history Making certain the medications and the doses are appropriate Educating the Patients about the Medications Documenting each change that is made along the way

34. Medication Reconciliation Summary 4. There are several approaches to reducing medication errors and each facility should develop processes that best fit

35. A Great American Philosopher It gets late early out there. Yogi Berra