Improving the care of your patients through the use of medication reconciliation

1. Improving the care of your patients through the use of medicationreconciliation PRISM 5, May 8th, 2008 Christopher Wellins, MD, MS GPMG Cape Elizabeth Center for Performance Improvement MMC

2. Goals • Understand what is meant by medication reconciliation. • Understand the importance of performing medication reconciliation and how this tool contributes to the quality and safety of the care that you provide

3. What is Medication Reconciliation? Medication reconciliation is the formal process of creating the most accurate list of home medications as possible and reconciling that list against any changes that are made across the continuum of patient care

4. What is Medication Reconciliation? • A JCAHO National Patient Safety Goal • Part of the Institute for Healthcare Improvement’s 100,000 and 5 million lives campaigns

5. Medication Reconciliation • Failure to reconcile medications on hospital discharge or when multiple care providers are involved can lead to adverse drug events. • National data indicates that 50 % of patients admitted to inpatient settings have at least one medication inadvertently omitted on their admission orders.

6. “I am an outpatient provider so why is this important to me?”

7. Case Studies • Patient comes to see his provider to request pain medication for lower back pain. • As part of the visit the provider obtains a medication history • Because of concerns regarding prescription of narcotic analgesics, the patient is given a prescription for tramadol.

8. Case Studies • Later that day, the pharmacy calls regarding a concerning drug interaction between tramadol and citalopram which the patient had not reported taking. • When the patient was called, he reported that he was taking citalopram as prescribed by a psychiatrist and he did not think that this was the business of his primary physician.

9. Lessons Learned • Obtaining a complete medication history from our patients is extremely important. • Patients frequently do not report over-the-counter medications or supplements unless explicitly asked. • Patients sometimes do not consider birth control pills to be medications. • Patients sometimes do not report use of psychotropic medications due to confidentiality concerns.

10. Case Studies • A patient comes to see his primary physician for follow-up of multiple medical problems. • This patient receives medications from a VA clinic. • The patient is treated for hypertension and one of his presenting complaints for the visit is lightheadedness.

11. Case Studies • Review of his history reveals that the VA prescriber had substituted felodipine for amlodipine, due to their formulary. • The patient did not understand that this was a substitution and thought that it was an addition. • Upon arrival in the office, the patient’s blood pressure was 84/50.

12. Lessons Learned • We need to be very explicit with our patients when we are making changes to their medication regimen. • Written instructions are a good supplement to verbal instructions. • Communication between providers regarding medication changes is crucial.

13. Case Studies • A patient who is on warfarin presents for an office visit with a concern regarding easy bruising. • INR is drawn at the office visit and comes back at 8.2. • INR two weeks ago was subtherapeutic and a change in dosing was recommended to the patient by phone.

14. Case Studies • The patient was taking 2.5 mg of warfarin daily (1/2 of a 5 mg tab). • The provider thought the patient had a 2.5 mg tab and instructed an increase to two tablets alternating with one tablet every other day with the intent of dosing at 2.5 mg/5 mg every other day. • The resulting dose that the patient took was 5 mg/10 mg every other day (!).

15. Lessons Learned • With warfarin in particular, but with all medications, providers need to be explicit when speaking to patients regarding whether a change has to do with number of tablets or dose (number of milligrams).

16. Outpatient Reconciliation • At initial visit, a complete list of home meds is generated. • Thereafter, the list is reviewed and updated when new meds are ordered and is given back to the patient. • If there are other providers of care who are not part of the clinic but are participating in the care of the patient, the list should be forwarded to them whenever it is updated.

17. Outpatient Reconciliation • Whenever any medication is given during an outpatient encounter (for instance joint injection with steroid) the following are required: • Home medication list is recorded or reviewed • Allergies are assessed • Home medications and allergies are considered in the context of any medications to be administered

18. Outpatient Reconciliation • Prior to an outpatient procedure you need to document that you have reviewed the patient’s medications • Post-procedure if any changes are being made to the patient’s regimen (holding medications, adding medications) a reconciliation needs to be done and the patient should be provided an updated and complete medication list

19. Outpatient Reconciliation • If a patient does not arrive at the facility with a medication list they are supposed to leave with one.

20. What Can You Do? • Keep your patient’s medication list up to date • Provide your patients with a medication list • Review medication lists with patients frequently, ideally at every visit. Be sure to ask about supplements, OTC’s , etc. • Encourage your patient to take their list to all doctor’s visits and have the doctor update the list when changes are made.

21. What Can You Do? • Convince staff that having accurate medication lists is crucial for safety and efficiency of office practice. If you have staff buy-in and everyone participates it will make the work a lot easier. • Try a performance improvement project around medication lists: • Plan a project to improve the number of your patients that carry a medication list. Obtain baseline data on a few days of the week • Do your intervention

22. What Can You Do? • Check how the intervention is working by performing more spot audits and asking staff how it’s going • Act on above information to make further changes and repeat the PDCA cycle.

25. What worked at MMC • Getting leadership on board • Frequent data feedback with peer comparisons • Rewarding excellent performers • Providers making “catches” based on performing a reconciliation

26. Summary of Challenges • Capturing the attention of busy providers • Lagging technology for electronic solutions

27. Medication ReconciliationTEAM • Joyce Mendozza, CPI • DonnaMorong, IS • DebraMullen, Nursing • Donald Watson, Pharmacy • ChristopherWellins, Physician • Roberta Barber, Pharmacy • Dan Bergeron, Nursing • Susan Curtis, CPI • Brian Marden, Pharmacy Additional help from Julie Marston (Accreditation and Regulation) as needed

28. Resources • An excellent section on frequently asked questions regarding medication reconciliation can be found on the JCAHO website www.jointcommission.org.