The 100,000 Lives Campaign: Prevent Adverse Drug Events Medication Reconciliation

1. The 100,000 Lives Campaign: Prevent Adverse Drug EventsMedication Reconciliation Institute for Healthcare Improvement

2. What Is Medication Reconciliation? • Reconciliation: A process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients anywhere within the health care system • Requires comparing the patient’s list of current medications against the physician’s admission, transfer, and/or discharge orders

3. Why Is This Important? • 50% of all medication errors and 20% of ADEs in the hospital are due to poor communication at handoffs. • 42% of the orders reviewed in pediatric cancer setting needed to be changed. • 30% of the time there were variances between medication orders and information from patient/guardian or prescription labels on the container.

4. Sample Results • 80% reduction in potential adverse drug events within three months of implementing medication reconciliation Michels RD, Meisel S. Am J Health-Sys Pharm. 2003;60:1982-1986.

5. Sample Results • 70% reduction in medication errors associated with reconciling medications in short seven-month period • 15% reduction in ADEs • Significant efficiency gains Time saved • At admission (nurse): 20-25 min. • Transfer from CCU: 25-45 min. • At discharge (pharmacist): 35-50 min. Rozich JD, Resar RK. JCOM. 2001;8(10):27-34.

6. Errors on Reviewed Charts per 100 Admissions Luther Midelfort Admission Reconciliation Discharge Reconciliation Transfer Reconciliation

7. JCAHO Patient Safety Goal Number 8: Accurately and completely reconcile medications and other treatments across the continuum of care • On admission to a new setting and with the involvement of the patient, obtain and document a complete list of the patient’s medications and other treatments, and reconcile the medications and other treatments with those at the previous setting of care. • For each patient, identify a licensed independent practitioner who is responsible for coordinating the patient’s care, including reconciling medications and other treatments during transition of care to other practitioners or other settings of care, and communicate the identity of that practitioner and how to contact him/her to all staff caring for the patient.

8. Why Is There a Problem? • No clear owner of the process • No standardized process in place • Difficult to obtain an accurate list • Not linked to admission orders • Not linked to orders as patients transition through different levels of care

9. Reconciliation Process Three Basic Steps • Verify: Collect an accurate medication history. 2. Clarify: Clarify any questions about drug/dose/ frequency. 3. Reconcile: Document why medication not ordered or changed.

10. What Is Included on the Medication List? • Current home meds / OTC / herbals, including dose, route, and frequency • Time of last dose • Source of the information • Patient adherence medication schedule Sample Reconciliation forms available on www.ihi.org

11. Reconciliation Form The RN completes this form when conducting the initial patient assessment.

12. Models for Patient Medication History • Nurse who completes the initial admission history and assessment also completes reconciliation form. • Pharmacist/pharmacy technician can take the medication history and complete reconciliation order form. • A physician can take the medication history as part of the intake process.

13. To Be Successful • Put the patient first. • Use a change methodology that accelerates improvement such as the Model for Improvement. • Simplify: Replace another process with a more efficient process.

14. To Be Successful (cont’d) • Align all stakeholders (physicians, nursing, pharmacy, administration). • Process and sub-process owners • A champion for the entire process • Provide ongoing education. • Resource the project appropriately.

15. Challenges and Barriers Culture • Bureaucracy • Complexity of communication • Issues of accountability • Lack of teamwork (e.g., physician resistance) • Failure to understand the gap between reality and what is possible • Failure to understand the criticality: harm to patients

16. Changing Culture • Recognize that this is HARD • Requires changing the way people do work • Difficult task, but not impossible • A story from our institution

17. Starting the Project • Understand the system in place. • Determine effectiveness of current process (collect baseline info). • Start at Admission (but it does not end there). • Start in an area where most likely to have success (e.g., pre-op)

18. Understanding the Current Process Example provided by UMass Memorial

19. Measurement Track number of unreconciled medications: • Randomly select 20 closed patient records from the pilot unit per month • Analyze records and count number of unreconciled medications • This can be tracked as number of unreconciled medications (numerator) over … • All medications in sample (as a percentage) • Patients in sample (expressed per 100 admissions) • These measures can be adjusted to focus on one particular area (e.g. admissions)

20. Data Collection Tools • Complete reconciliation data form within 24 hours of admission. • It is given a “Yes” if it is completely reconciled.

21. Using the Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do

22. Start Small • Start with small tests of change: 1 unit, 1 RN, 1 MD, 1 patient • Test on pilot unit • Refine the process • Test on all shifts • Test on all patients

23. Ingredients for Success • All three stakeholders in the process—MD, RN, pharmacy—must be involved. • Teams without nurses fail. • Teams led by pharmacists may be less successful, lacking leverage. • Physicians must be part of the team.

24. Role of Leadership • Commitment: This cannot be done without leadership support. • Set the standard: “This is how we will practice.” • Resources: Allow time to work on testing. • Use data: To motivate, to know if changes are leading to improvement

25. Role of the Patient • Include patients in planning. • Ask patients to help design and test medication cards. • Share with patients the importance of maintaining and carrying an up-to-date medication card.

26. Personal Medication Record

27. Discharge Medication Calendar

28. Spreading the Process • Test and spread the reconciliation process to other admission areas. • Begin testing how to reconcile on transfer. • Plan for medication reconciliation at discharge.

29. Complete details about the 100,000 Lives Campaign, including materials, contact information for experts, and web discussions, available on the web at www.ihi.org.