1. Hilary Rowe BSc(Pharm) VIHA Pharmacy Resident 2009-10

2.  Prompted by Required Organization Practice (ROP) of Accreditation Canada Recommendations of Safer Healthcare Now!  Determine potential impact of a medication reconciliation process at the Royal Jubilee Hospital Emergency Department (RJH ED)

3. 1. Documenting a complete and accurate list of home medications called a Best Possible Medication History (BPMH) 2. Resolution of discrepancies between BPMH and home medication admission orders

4.  Prospective  Phase I- Baseline Study  Phase II- Pilot Study  Sample size calculation 28 patients required to show a 75% decrease in discrepancies compared to baseline

5.  Primary Objective Quantify home medication discrepancies without proactive reconciliation by 2400hrs one day post presentation to the ED  Secondary Objectives Characterize the severity of home medication discrepancies (Drug Related Problems [DRP] and medications involved) Determine if the discrepancies were undocumented intentional or unintentional

6.  Patients admitted to RJH ED  Patient signed consent form  Required admission medication orders written in ED Orders written in chart by 2400hrs one day post presentation to the ED

7.  Clinical Teaching Unit (CTU) patients  Patients going directly to procedural locations  Patients under 18 years old  Patients in Psychiatric Emergency Services, who were violent or in isolation

8.  BPMH-after admission orders Asked about OTC & Rx therapy Looked at medication bottles & lists Checked PharmaNet Talked to family as needed  Compared home medication admission orders to BPMH by 2400hrs one day post presentation to the ED  Documented discrepancies identified

9. 0= No discrepancy 1= Intentional discrepancy- physician made intentional choice to add, change or discontinue a medication and it was clearly documented 2=Undocumented intentional discrepancy- physician made intentional choice to add, change or discontinue a medication but it was not clearly documented 3=Unintentional discrepancy- physician added, changed or discontinued a medication unintentionally 4=OTC discrepancy (this type of discrepancy was added by the investigative pharmacists to describe natural health products and vitamins that were not prescribed)

10. Mean number of medications per patient=9.7

11.  Primary Objective Quantify the change in discrepancies when comparing the number of baseline discrepancies to the number of discrepancies found after a medication reconciliation intervention  Secondary Objectives Characterize the severity of home medication discrepancies (DRP’s and medications involved) Determine if the discrepancies were undocumented intentional or unintentional

12.  BPMH -within 24hrs of presentation Same interview process as Baseline Study BPMH left in chart Clinical pharmacy note outlining discrepancies was left in chart  Compared home medication admission orders to BPMH by 2400hrs one day post Medication Reconciliation intervention  Documented discrepancies found

13. Mean number of medications per patient=8.23 Mean time required per patient = 32 min (15-65 min) *64% decrease

14.  Come see my poster for more information…

15. 1. Safer Healthcare Now!. Medication reconciliation (acute care) getting started kit. [Internet]. Canadian Patient Safety Institute; [updated 2009 Jan 19; cited 2009 Nov]. Available from: http://www.saferhealthcarenow.ca/EN/Interventions/ medrec_acute/Documents/Med%20Rec%20(Acute%2 0Care)%20Getting%20Started%20Kit.pdf