Medication Reconciliation

Medication Reconciliation Insert your hospital’s name here

Agenda • Define the problem • What is medication reconciliation? • CheckPoint measure • Things to consider when developing a process • Keys to success

What is the problem? • Hospitalized patients who experience an adverse drug event (ADE) are twice as likely to die as those without an ADE (JAMA 1997; 277:301-306) • The Institute of Medicine has estimated that medication errors account for 7,000 deaths annually (To Error Is Human: building a safer health system, 1997, IOM) • ADEs account for 6.3% of malpractice claims (Arch Intern Med. 2002; 162:2414-2420)

Where is the problem? • Chart reviews revealed that 50% of all medication errors and 20% of adverse drug events are due to poor communication at the interfaces of care (Institute for Healthcare Improvement 2005) • Patient admission to the hospital • Patient transfer out of specialty units to other nursing units • Patient discharge from the hospital

Why? • Interfaces lack a process for comparing the patient’s most current list of medications against physician orders for admission, transfer, and discharge

Examples of interface problems • Physician admission orders read “continue home meds” • Patients transferring from a critical care setting to a nursing unit would still have lidocaine drip listed on their medication record • Patients’ discharge orders read “discharge on home meds”

What is Medication Reconciliation? • A process of identifying the most accurate list of medications a patient is taking and using this list to provide correct medications for the patient anywhere within the health care system

How Are Medications Reconciled? • Verify: Collect an accurate medication history • Clarify: Compare the patients list of current medications – including name, dosage, frequency, and route – against the physician’s orders. Any medication that does not match must be “reconciled” by bringing the discrepancies to the attention of the physician • Reconcile: Document the change or why the medication was not ordered to communicate to the healthcare team

When are Medications Reconciled? • Admission • The patient’s home medications are compared to the physician’s admission medication orders • Transfer One Unit to Another Unit • The patient’s most current medication record is compared against the physician's transfer orders • Discharge • The patient’s reconciled list of admission medications is compared against the physician’s discharge orders

Sample High Level Medication Reconciliation Process Patient Profile H&P/Clinic Note/Outpt Pharmacy Reconciled Admission Med List Latest MAR Admission Orders Reconciled Discharge Med List Discharge Orders

Medication Reconciliation is Viewed as a Quality Measure • JCAHO 2005 safety goal • IHI 100K Lives Campaign • WI Node 100K Lives Web site • Statewide improvement team (PSW/WHA) • CheckPoint Error Prevention Measure • It is the right thing to do, but very challenging to implement

WI Hospital Medication Reconciliation Survey – June 30, 2005 N=57 Wisconsin Hospitals

CheckPoint Scoring • Each hospital that volunteers to publicly report on the medication reconciliation measure will have their score posted to the CheckPoint website with the other Error Prevention measures • The medication reconciliation score will consist of a composite number ranging from 0-100 points • The points are cumulative based on the hospitals response to 4 components

4 Components of the Score

Goal 6 DSR – Medication Reconciliation Number of cases that have a complete medication reconciliation form in their medical record within 48 hours of admission ____________________________________ X 100 Total number of cases reviewed

What is a “complete” form? • All fields required by your hospital’s policy are complete on the form • Must include medication name, does, frequency, route and reconciliation status • All medications are reconciled with a • Medication order OR • Documentation that the medication was not ordered • All required signature are present • Must have at least 2 signatures from different disciplines

What Medications are Included? • All medications on the patients current home medication record should be reconciled • Prescription • Over-the-counter • Homeopathic • Vitamins • Herbals • Nutritional supplements • If your hospital has a policy that excludes OTC, homeopathics, vitamins, herbals, or nutritional supplements from reconciliation, you may consider these medications reconciled

Reconciliation Definitions • If a medication is on the patient’s current home record, but no order is written, it is reconciled if: • Documentation that it is not being ordered • Contraindicated for the admitting condition • If the patient is NPO on admission and no medications are ordered, the case is reconciled

48 Hours • Use the inpatient admission date and time to determine the 48 hour window • Make sure that the date and time the reconciliation was completed is on your reconciliation form

Case Selection • Minimum number is 75 cases in 6 months • Inclusion criteria • All patients admitted for inpatient services including admits from the ER and direct admits • Exclusion criteria • LOS based on admit date and time of <48 hours • Patient unresponsive on admission and you cannot obtain a medication history from a competent source • Newborn born during that admission

CheckPoint Report • WHA will start reporting the medication reconciliation measure March 15, 2006 as part of the CheckPoint Error Prevention report www.wicheckpoint.org • The data will be updated every 6 months

Optional Internal Measures • Number of reconciled medications • Number of medication errors after reconciliation • Number of adverse medication events related to non reconciliation • Number of admissions reconciled

Things to Consider • Admission • Sources of information • Patient and family (have patient bring meds?) • Physician’s office • Patients pharmacy • Past medical record • Transfer form • Format? • What medications are included? • Who does it? • Speed and accuracy • Discrepancies • What will the process be? • Who follows up? • Reconciliation • Who does it?

Transfer • Compare medication lists before and after a transfer or procedure • Check home meds • Who does it?

Discharge • Review 3 lists • Current meds • Home Meds • Discharge orders • Document format • Who does it? • Patient Education • Address hospital formulary changes • Who gets the discharge medication list? • Encourage patient to maintain a accurate medication list over time

Team effort, but who does what? • Physician • Best knowledge of patient • Decision maker/write the orders • Nurse • Best access to patient and family • Frequently does the admission history • Frequently does the discharge education • Pharmacist • Best knowledge of drugs and formulary • Limited patient and family access • Hosp/community pharmacy interface • Transfer reconciliation

Patient • Real decision maker • Variable motivation factors that need to be included • Need tools to keep track of medications • Administration • Realize the gravity and challenges of the process • Prioritize clinical resources • Culture of patient safety

Keys to Successful Implementation • Teamwork! • Commitment to improve by nurses, pharmacists, physicians, and administration • Baseline and ongoing data collection to track progress • Policies and procedures to govern the process • Well designed and communicated processes • Thorough evaluation of existing processes including a high level flowchart of the existing process to determine where problems exist • Flowchart new process to assure new problems not created and to use as a communication tool

Create/adopt forms to document reconciliation at admission, transfer and discharge • May have one or many forms • Forms may be paper, electronic, or a combination of both • Remember to review computer systems to determine if there are links to existing information that could be utilize • Educate staff to assure that everyone understands and can use the new process consistently

It’s effective!

Medication Reconciliation