1. © Institute for Safe Medication Practices Canada 2009® Passing the Baton: Medication Reconciliation at Internal Transfer and Discharge Olavo Fernandes PharmD, FCSHP ISMP Canada Safer Healthcare Now! National Call Sept 10, 2009 LCD Version

2. © Institute for Safe Medication Practices Canada 2009® Slide 2 Objectives At the end of this session, participants will be able to: 1. Outline the key elements and general principles of an interdisciplinary internal transfer and discharge practice process. 2. Highlight strategies for overcoming common challenges to successfully implement medication reconciliation at discharge and transfer. Open Discussion Forum: 3. To provide participants with an open forum for sharing current challenges, successes, lessons learned and controversies with medication reconciliation implementation at transfer and discharge.

3. © Institute for Safe Medication Practices Canada 2009® Slide 3 Moving On From Admission…. Feedback from teams: many have started and moved toward sustaining admission med rec and are now earnestly focused on internal transfer and discharge Requests to represent and revisit key principles of effective reconciliation at internal transfer and discharge

4. © Institute for Safe Medication Practices Canada 2009® Slide 4 Unintentional Discrepancy Rates Admission* 5/10 patients (Cornish P, Arch Int Med 2005;165:424) Transfer* 6/10 patients (Lee J, 2007; manuscript submission) Discharge* 4/10 patients (Wong J. Ann Pharmacother 2008;42:1373-9) *~Many of these discrepancies are clinically significant J Harrison TGH

5. Practical Overview of Medication Reconciliation in Acute Care

6. Summary of the Medication Reconciliation Process at Admission

7. Summary of the Medication Reconciliation Process at Internal Transfer and Discharge

8. © Institute for Safe Medication Practices Canada 2009® Slide 8 Medication Reconciliation at Internal Transfer Internal transfer is an interface of care associated with a change in patient status where medications are assessed and medication orders should be reviewed and updated Internal transfer may include: Change in responsible medical service Change in level of care (critical care unit to hospital ward) Post-operative transfer and/or Internal Transfer between units

9. © Institute for Safe Medication Practices Canada 2009® Slide 9 Medication Reconciliation at Internal Transfer The goal of internal transfer is to ensure all medications are appropriate for the patient’s new status of care. The Best Possible Medication Transfer Plan (BPMTP) is the most appropriate and accurate list of medications the patient should be taking after the transfer.

10. Summary of the Medication Reconciliation Process at Internal Transfer and Discharge

11. © Institute for Safe Medication Practices Canada 2009® Slide 11 Medication Reconciliation at Internal Transfer Internal transfer medication reconciliation involves assessing and accounting for: the medications the patient is taking prior to admission (BPMH) the medications from the transferring unit (medication administration record (MAR) the new post-transfer medication orders (includes new, discontinued and changed medications upon internal transfer).

12. © Institute for Safe Medication Practices Canada 2009® Slide 12 Subset - National Survey What Is The Optimal Strategy For Internal Transfer? Wong C et al. UHN/ ISMP

13. © Institute for Safe Medication Practices Canada 2009® Slide 13 National Transfer Medication Reconciliation Team Descriptions Wong C et al. UHN/ ISMP

14. © Institute for Safe Medication Practices Canada 2009® Slide 14 Wong C et al. UHN/ ISMP Key Elements of Interdisciplinary Practice Model for Medication Reconciliation at Internal Transfer (from national survey and clinician interviews) Wong C et al. UHN/ ISMP 1.Best Possible Medication History on admission 2.Clear assignment of responsibilities 3.Clear expectation of timeframe 4.Standardized tool / process 5.Comprehensive communication to all team members 6.Auditing and sharing results with staff 7.Standardized interdisciplinary clinician training 8.Support from leadership/ stakeholders

15. © Institute for Safe Medication Practices Canada 2009® Slide 15 National Snapshot Of Transfer Medication Reconciliation Wong C et al. UHN/ ISMP

16. © Institute for Safe Medication Practices Canada 2009® Slide 16 Transfer: Clinicians Primarily Responsible Wong C et al. UHN/ ISMP

17. Sample Process: computer generated paper- based transfer orders form community hospital Used with permission from Markham Stouffville Hospital

18. Medication Reconciliation at Discharge Should result in clear and comprehensive information for the patient and other care providers The Best Possible Medication Discharge Plan (BPMDP) is the most appropriate and accurate list of medications the patient should be taking after discharge. Should account for: The Best Possible Medication Discharge Plan (BPMDP) is the most appropriate and accurate list of medications the patient should be taking after discharge. Should account for: 1.New medications started in hospital 2.Discontinued medications (from BPMH) 3.Adjusted medications (from BPMH) 4.Unchanged medications that are to be continued (from BPMH) 5.Medications held in hospital 6.Non-formulary/formulary adjustments made in hospital 7.New medications started upon discharge 8.Additional comments as appropriate - e.g. status of herbal medications/ supplements or medications to be taken at the patient’s discretion

19. FOR WHOM? : Discharge Reconciliation Safer Health Care Now! GSK: Med Rec 2007 Best Possible Medication Discharge Plan (BPMDP) should be communicated to : Patient Community Physician / Primary Care Physician Community Pharmacist Other Community health care providers Alternative Care Facility or Service Clearly Communicate Medication Status: New, Discontinued, Adjusted or Unchanged Suggested/ preferred reference point for community clinicians: changes since admission to hospital

20. Synchronization Challenge of Discharge Tools Patient Care System Dear Dr Letter EMITT Letter Patient schedule Discharge Prescription Patient Wallet card J. Wong BScPhm ManualElectronicElectronic

21. Wong J. [Abstract] Pharmacotherapy 2006 ;26: 106 Medications may be altered: new, adjusted, discontinued Ward Decision to discharge patient BPMDP Home Synchronized Outputs Discharge Reconciliation Electronically Generated Prescriptions Medication Information Transfer Letter Patient Medication Grid Patient Medication Wallet Card 2345 Best Possible Medication Discharge Plan Physician Discharge Summary 6

23. Vertical : Patient Medication Grid

24. Patient Friendly Discharge Medication List Used with permission from Markham Stouffville Hospital DOCTOR: LOCATION: PATIENT:

25. Medication Reconciliation at Dryden Regional Health Centre Transfer & Discharge WOW what a journey!! Lorie-Anne Blair Director of Patient Safety & Clinical Education

26. DRHC

27. Dryden Regional Health Centre  Dryden is centrally located in the most western portion of North western Ontario, approximately 360 km from Thunder Bay and 320 km from Winnipeg  41 beds - 31 acute care and 10 chronic care  Approximately 20,000 Emergency room visits per year.  Average about 100 births per year.  33% of all hospital patients are over 65 years of age and 15% are children.  We have three operating theatres.  And a variety of outpatient departments.

28. Medication Reconciliation  Senior Management at DRHC made Medication Reconciliation a priority in February 2008.  A committee was formed which included: Senior VP Director of the In-patient unit Physician Nursing Supervisor Pharmacist RN RPN Director of Patient Safety CCAC 2 Community Pharmacists

31. Transfer & Discharge Medication Reconciliation  Admission Med Rec. implemented in January 2008  Transfer & Discharge implemented in January 2009  Form changed significantly due to feedback from staff over time and the desire to include all three processes on one sheet.

33. Transfer Medication Reconciliation – The process  The only internal point of transfer was from East Unit to OR and back.  The paper form was placed with an in hospital med list for review by the MRP post operatively.  Med Rec. was completed by the Recovery Room nurse and the patient was returned to the floor.

34. Discharge Medication Reconciliation – The other process  Upon discharge the Physician reviews the Med. Rec. form and in hospital medications and incorporates the home meds. into their discharge orders.  The Discharging Nurse reviews the BPMH and compares them to the discharge orders and rectifies any discrepancies.

35. Auditing the Processes  In Jan 2009, audit process was changed to reflect all three processes.  We had fully implemented Admission Med Rec. and no longer found the discrepancy rate valuable – now we needed to focus on completion rates.  I collect all Med Rec’s from Clinical Records and analyze data

38. No peaking!!

39. Extremely powerful data!! The graph of shame! % of Physician completion of Discharge Med. Rec.

40. Ahhhhhh!!! Transfer Med. Rec. One lonely signature!!

41. Successes  Admission Medication Reconciliation is standard procedure and Physicians are completing greater than 95% of Admission Medication Reconciliation’s.  Much better collaboration between Physician, Nurse and Pharmacist on Admission.  We have seen a 50% decrease in the number of medication incidents. There have been other interventions implemented during this time to decrease Medication Errors – not all the decrease can be attributed to Med. Rec., but a significant portion can be.

42. #1 Incident report generator

43. Less than 50% of last years #’s

44. Challenges  Buy in from the MRP and visiting Specialists.  Buy in from the staff.  Nurses forgetting where to sign.  Form changes: should have used small PDSA cycles rather than edits and trials with all staff – even though we were small

45. Plans  1:1 meetings with Nurses & Physicians to review process  No further changes to forms  Development of a tracking method for staff to identify good catches of unintentional discrepancies.

46. © Institute for Safe Medication Practices Canada 2009® Slide 46 OPEN FORUM

47. © Institute for Safe Medication Practices Canada 2009® Slide 47 Common Challenges and Strategies in Internal Transfer

48. © Institute for Safe Medication Practices Canada 2009® Slide 48 Common Challenges and Strategies in Discharge Used with permission by : EHR and Medication Reconciliation US Panel

49. Medication Reconciliation in the Community ISMP Canada / O. Fernandes UHN

50. Framework: Ambulatory Medication Reconciliation Model Framework: Ambulatory Medication Reconciliation Model Creating the most “up to date” medication record (BPMH) (UHN/ SHN Home Care Pilot) Patient and Family Interview Medication Information from all other sources document “up to date” medication record (BPMH) “medication discrepancies that require clarification” Compare: Review and follow up where indicated Examples: Medication vial inspection Referral record Community pharmacy Hospital Discharge Summary

51. © Institute for Safe Medication Practices Canada 2009® Slide 51