1. Measuring the value of medication reconciliation – Part 2 Discharge processes at AHS Tiing Tiing Chih Yang Liu Dr Stephen Lim (Acknowledgement: all senior pharmacists at AHS)

2. History of Med Rec at AHS AHS started admission MR in 2007 as part of WA SQuIRe projects “M+M” project – medication matching AHS = first hospital to introduce KPIs for Adm Med Rec % of unintentional discrepancies = 17%  Ave 17 unintentional discrepancies for 100 meds written i.e. for a patient on 10 medications, 1-2 of the medications will be an unintentional discrepancy

3. WHO’s High 5s project from 2010 Benefits = new measures MR1 50% MR2 < 0.1 MR3 Canadian benchmark 0.3 AHS: MR4 Trending down, last result = 10% Event Analysis

4.  Event analysis beneficial as a “fact finding” tool investigate patient safety problems to identify if there are problems with the SOP to identify cause and effect Multidisciplinary approach Less labour/resource intensive than RCA Measurable actions & changes to implement to improve patient safety

5. It’s discharge time! DC med rec started late 2007 Pharmacist involvements: Med list, CMI Dispensing Counselling Community liaison

6. Discharge Process DC script Med chart MMP Med list DC Meds Counselling DC liaison CMI Pharmacist reconciliation Discharge decision made

7. Medication reconciliation on discharge Develop medication list Communicate D/C summary with medication list to GP Proactive model Pharmacist: Reviews and reconciles : BPMH (MMP) Current medication charts New medicines to start on discharge PBS prescription Patient’s Own Medicines Resolves discrepancies Provide medication list to patient Medical officer: Checks MMP for outstanding issues Reconciles with medication charts Signs off NIMC Writes PBS script for items requiring supply Add medication list to discharge summary Decision to discharge patient Patient shows to GP/others

8. Discharge summaries at AHS Prior to 2009: Medipal Standalone system “11 th hour changes” not communicated Discharge summary sheets Handwritten by dr on pre-printed format Nil or only new meds listed ?? GP liaison ?? Patient copy

9. Discharge summaries at AHS TEDS (The Electronic Discharge System) implemented in 2009 Pharmacists populate ADR & med list “Import” function allows direct copying of meds from most recent completed TEDS On completion, GP will automatically be emailed

10. TEDS medication discharge list example Current and comprehensive list of medicines Dose changes, indications, explanations of change Comments section: can use to provide monitoring advice Includes stopped medications Includes Allergies/ADRs

11. Discharge summaries audit Big improvements since TEDS implementation in 2009 QUM 5.3,5.8, 5.9

12. Discharge Discrepancies Omission Wrong dose Wrong drug Commission ADR

13. One week DC snapshot Total discharges surveyed = 61 No active Pcist reconciliation = 22 (36%) Nil MMP Low risk pts DC reconciliation = 39 (64%) Pts with discrepancies = 20 (51.3%) Average discrepancies per pt = 0.72 % incorrect meds per pt = 13% (i.e. at least 1 error per 10 meds taken) PBS & legality check Rx to chart matching Med list not done by Pcist

14. Comparison of Adm & DC MR errors Discharge errors Admission errors

15. Richard’s discharge  Admitted for fast AF, CCF secondary to AF, ? Chest infection  Meds on admission: Thyroxine 25microg mane Salbutamol-MDI prn  New meds: Digoxin 125microg mane (loading 250microg x 2) Frusemide 40mg mane Metoprolol 12.5mg bd Warfarin + enoxaparin tx dose until INR therapeutic Amoxycillin 500mg tds

16. Richard’s DC script Warfarin & enoxaparin missing!

17. Lucy’s discharge Admitting diagnosis: NSTEMI Meds on admission: Allopurinol 100mg mane Methyldopa 250mg bd Paracetamol-SR 1330mg tds New meds started on AMU: Aspirin 100mg mane Ticagrelor 180mg loading then 90mg bd Metoprolol 12.5mg bd DC Rx : frusemide & potassium chloride (Dr thought pt was already taking antiplatelets)

18. Risk factors contributing to DC discrepancies  Multiple med charts  Nil MMP in place  Brand name confusion  Dr not referring to MMP when doing DC script or summary  Dr from different team handling DC

19. Challenges for DC med rec  Time / FTE  Nil MMP in place  Dr not contactable to verify discrepancies  Late / urgent discharges

20. Conclusion  AHS measures coincide with High 5s measures  MR6 MR6a (% pts whose DC summaries contain a med list) MR6b (% pts whose DC summaries contain a current, accurate and comprehensive list of meds) MR6c (No. discrepancies per pt)  MR7 MR7a (% pts who receive a med list) MR7b (% pts who receive a current, accurate and comprehensive list of meds) MR7c (No. discrepancies per pt)