Medication Reconciliation at Peach Arch Hospital

1. Medication Reconciliationat Peach Arch Hospital Pam McCarthy RN October 4, 2006

2. What is Medication Reconciliation? • Medication Reconciliationis the formal process of obtaining acompleteandaccuratelist of each patient’s home medicationsAND the act of reconciling the list to the physician’s orders written onadmission, transfer and at discharge. • Any variance from the home medications are resolved and documented. • Goal is to prevent adverse drug events (ADE)

3. Medication Reconciliation • Obtaining a complete and accurate, Best Possible Medication History (BPMH) is a collaborative effort involving: Patient

4. What is Safer HealthcareNow! • Safer Healthcare Now! campaign is aimed at reducing preventable complications and deaths in Canadian hospitals. • Patterned after the 100K Lives campaign established by the US Institute for Healthcare Improvement • The campaign consists of six targeted, evidence-based strategies to improve patient care • Fraser Health has signed on to fully participate in the campaign

5. Where are we in Fraser Health? • Identification of ER Pilot Site Team co-leads • Dr. Kerry Yoshitomi • Jodi Krotje • Interdisciplinary ER Team • ER Physician – Dr. J. Hendry • ER RN – Pam McCarthy • ER CNE - Jennifer McDuff • ER Pharmacist – Dr. Susan Buchkowski • QI/Patient Safety Consultant – Barb Saunders/Marianne Southwell • Medication Safety Coordinator – Janice Munroe

6. Where are we in Fraser Health? • Identification of Medicine Pilot Site Team co-leads • Dr Antonio Benitez • Carole Kisielius • Interdisciplinary Team • Vicki Reilly RN • Caroline Mojak CNE • Gerry Watts Pharmacist • QI/Patient Safety Consultant – Barb Saunders/Marianne Southwell • Medication Safety Coordinator – Janice Munroe

7. Pilot Team - Implementation Plans • Process flow mapping • Identify resources required to complete • Budget submission • Develop processes and forms • Multiple PDSA cycles following Quality Improvement principles and application of the Collaborative Learning Model

8. A differentapproach… • Improvement methodology rather than research methodology • Small tests of change rather than controlled trials • Small sampling rather than randomized formal sampling • Concurrent collection of key data rather than retrospective comprehensive evaluation • Learning rather than judgement

9. Model for Improvement Act Plan Study Do What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Adapted from: The Institute for Healthcare Improvement

10. What Changes Will We Make - The PDSA Cycle Act Plan • Objective • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data

11. What are we trying to accomplish? • Write a clear aim statement • Define the population • Define boundaries/limitations • The aim statement is meant to keep the team focused Adapted from: The Institute for Healthcare Improvement

12. What is the goal of Medication Reconciliation? • Reduce adverse drug events (ADE) by reconciling medication orders at all key transition points in order to: • Eliminate undocumented intentional discrepancies • Eliminate unintentional discrepancies • Increase the number of medication orders that are reconciled (success index)

13. How will we know that a change is an improvement? • All intentional discrepancies are documented - initially to improve by 75% from baseline • All unintentional discrepancies are eliminated - initially to improve by 75% from baseline • Medications are reconciled – initially to increase to 90% of ordered medications

14. Medication ReconciliationBaseline Data • 20 patients reviewed at Peace Arch Hospital in December 2005 • 134 medications ordered => average of 6.7 meds per patient • Per patient, 0.9 (13%) orders were changed without a documented reason. The lack of documentation could result in an inappropriate correction or error. • There were 1.45 (22%) unintentional discrepancies per patient. These are medication errors. • Calculated Success Index = 65% ie. 35% of the written orders are in error or have the potential to result in error

15. Testing on a Small Scale Conduct the test: • in one unit, with one nurse, physician etc. • with a small number of patients • over a short time period Adapted from: The Institute for Healthcare Improvement

16. D S P A A P S D D S P A A P S D A P S D AIMDecrease undocumented intentional discrepancies and unintentional discrepancies by 75% of baselineIncrease the Success Index to 90% Adapted from: The Institute for Healthcare Improvement Reduced Adverse Drug Events DATA Cycle 10: Patient/Family complete form @bedside if on 3 or > meds Cycle 9: Patient/Family complete form @bedside Cycle 8: Patient/Family complete form @ triage if on 3 or > meds Cycle 7: Patient/Family complete form @ triage Cycle 6: Bedside nurse using the form on admittedpatients on 3 or more meds Cycle 5: Bedside nurse using the form on admittedpatients on meds Forms and processes to support Med Rec Cycle 4: Bedside nurse using the form on alladmitted patients Cycle 3: BPMH form at triage for patients on 3 or > medications Cycle 2:BPMH form at triage for patients only if on medications Cycle 1: BPMH form at triage for all patients

17. Using Data – The Run Chart • Evaluate data regularly (15 audits/month) • Continue to run PDSA cycles • Evaluate what is happening in the process • Regularly report results to: • Frontline staff • Site team members • FH Medication Reconciliation Steering Committee • FH SHN Steering Committee/Quality Council • SHN Western Node

18. Annotated Run Chart- PAH

19. Annotated Run Chart – PAH

20. Annotated Run Chart – PAH

21. Pilot Team – Current Status at PAH • ER Go-live date was August 21 • Continue PDSA cycles to resolve process and form issues • Targeted chart audit to provide feedback to ER staff • Established Medicine team • Joint ER and Medicine team meetings to share learnings

22. Items for consideration…… • Support to continue audits to ensure that the practice is sustained over time and that the improvement holds • Site Team evolution as spread occurs • Spread to other FH sites – multiple vs single? • Community involvement – phase I or II or??