1. Medication Information Management and Error Recovery in Primary Care Tosha B. Wetterneck, MD, MS Associate Professor of Medicine, University of Wisconsin School of Medicine and Public Health Researcher, Center for Quality and Productivity Improvement, University of Wisconsin-Madison

2. Medication Safety at Transitions of Care (TOC)  Transitions of care are risky for pts 10-23% of pts experience errors & adverse events, many medication related  Many adverse events after TOC are preventable  Lack of communication / information flow major factor  No studies of how PCPs recover from information failures Forester et al, 2003 & 2004; Schnipper et al, 2006; Coleman 2005; Smith et al 2005; vanWalraven et al 2002; Bell et al 2008

3. Assessing Risk in Ambulatory Medication Use after Hospital Transitions*  Specific Aims: To assess transitions of care from hospital to ambulatory primary care from a primary care perspective 1.To analyze the system failures in the medication information management (MIM) process. 2.To evaluate the methods for detection of failures and the subsequent correction of failures in the MIM process. *AHRQ K08HS17014

4. Methods  3 Primary care clinics & associated hospitals Varied by EHR use, rural/urban location, organizational ties, continuity of care 18 PCPs, 26 RNs/MAs 100+ patient visits  Observations of clinician work & pt visits and interviews of PCPs, nurses & patients

5. Data collection: med information flow - communication  Failures / errors  Error recovery Detection Explanation Correction  Missed opportunities for recovery  Consequences  Contributing factors

6. Failure / Error Recovery ErrorDetectionCorrection Explanation Outcomes Failure

7. Anatomy of pt-visit related observations  Pre-visit work: PCP & Nurse Review pt info, CC, last visit, prob list  Intake for pt visit: Nurse Vital signs, review medication list, allergies  Provider visit: PCP  Post-visit work: PCP & Nurse Documentation, referrals, Rxs, billing  PCP & nurse may verbally or electronically communicate

8. Paired Observations **1 HFE + 1 HF-MD observing a PCP- nurse pair for half day  Able to follow both clinicians for entire pt visit, pre & post work ID failures & recovery across clinicians Teamwork / coordination  HFE & MD share insights from medical & HF viewpoints  Downside: space constraints

9. Preliminary Analyses  Failures are common: up to 50% visits  Common failures Lack of complete med list verification  Only med name checked with pt Med list not complete:  Lack of OTC med documentation  Not asking about “other meds” Duplicate meds on list Changes in dose / dose form not documented Compliance not documented

10. Scenario: Nurse observation  Nurse checks in new pt for clinic visit Pt called 1 wk earlier for appt, got Rx for Ambien 10mg nightly over phone for insomnia  Nurse reviews med list in EHR (Ambien) & checks that pt is taking med, reviews allergies, smoking hx & chief complaint  Pt states Ambien not working well, took double dose x 2 days and still not sleeping  Nurse tells pt he should not take more med than prescribed. Does not document pt taking higher dose.

11. PCP observation  MD greets new pt, 20min late for appt Reviews pts medical hx, social hx  MD notes pt’s BP is high (not on meds) and that pt smokes & discusses implications with pt  MD discusses insomnia and Ambien use (now 15 min into 15 min visit) Pt states medication not working well MD tells pt to take 2 tablets nightly to see if this helps  MD tells pt to f/u in a few weeks with longer visit to discuss multiple problems

12. Analysis  Paired observation reveals info failure: MD did not have accurate med info Lack of nurse documentation of 20mg dose  Lack of expectations for doc med history, info  Not easy to indicate pt taking more med Focus on “list of meds”, ? Pt expected nurse documented conversation Nurse comment to pt may have prevented pt from admitting higher dose to MD Time pressure: new pt, short visit, other problems

13. Recovery scenario  70 y/o man here for f/u BP visit  Nurse takes VS, reviews allergies.  MD knows pt well. Reviews BP and need for more medication w/ pt.  MD reviews written med list in front cover of paper chart. List has many meds crossed off over time. MD asks pt what he is taking for BP. Pt shakes his head and says he can’t remember the name.

14.  MD reviews prior notes and asks pt if it is Doxazosin. Pt asks if that is the prostate med? MD states it does both. MD asks what dose he is taking. Pt states he doesn’t know but its one pill a day.  Between reviewing notes and med list, MD is uncertain of the dose that pt is taking. MD spends 10 min describing two scenarios based on the dose he is taking– one to double the dose, the other to make a small increase. MD confirms pt’s pharmacy.

15.  MD tells pt he should keep a med list with him and ends visit.  MD jots note about increasing med for BP.  MD sees 4 more pts, then sits to complete chart documentation.  MD calls the pharmacy, asks the RPh about the last Rx dose. It was a higher dose than what was documented on the med list. MD tells RPh she is faxing a Rx for a higher dose and asks RPh to give pt a med list.  MD calls pt about med increase & updates med list in chart.

16. Analysis  Failures: Medication list incorrect  Detection: MD “error suspicion”  Correction attempts: Reviews chart supporting documentation but cannot confirm med dose Calls Pharmacist and confirms dose  Consequences: MD time, ?pt confusion

17. Analysis  Contributing factors Pt does not know meds, reasons taking them Medication list in chart not up-to-date  Missed earlier recovery? Medication list could be updated before MD sees pt  Pre-visit or during intake by RN

18. Conclusions  Failures are common in the medication management process in primary care  Failures are normalized; treated as part of everyday practice  Recovery is common and built into normal work processes  Understanding failures & recovery mechanisms may guide the building of more robust work processes and decrease information failures & consequences to PCPs and pts

19. Acknowledgments  Mentor: Pascale Carayon, PhD  Advisory committee: Paul Smith, Maureen Smith, Mark Linzer  Research Team: Talley Holman, Jamie Lapin, Dan Krueger, Peggy O’Halloran  WREN  Funding: AHRQ K08HS17014 Dept of Medicine R&D grant, UWSMPH

20. Thank you!