How Medication Reconciliation Supports Patient Safety 15 September 2007

1. How Medication Reconciliation Supports Patient Safety15 September 2007 Jane Richardson, BSP, PhD, FCSHP Coordinator, Clinical Pharmacy Services Team Lead, SCH Med Rec Pilot Site

2. Objectives • To define Medication Reconciliation & describe why it’s important. • To outline our initial experience with admission Medication Reconciliation within the Saskatoon Health Region (SHR). • To describe early use of the Pharmaceutical Information Program (PIP) auto-populated Medication Reconciliation form in SHR Emergency Departments.

3. Medication Reconciliation – what is it? • A formal process of: • Obtaining a complete and accurate list of each patient’s current home medications (name, dosage, frequency, route) • Comparing the physician’s admission, transfer, and/or discharge orders to that list • Bringing discrepancies to the attention of the prescriber and ensuring changes are made to the orders, when appropriate Reference: IHI, Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation)

4. Institute for Healthcare Improvement • The Institute for Healthcare Improvement introduced the 100K Lives campaign, December 2004, to challenge health care providers to join a national effort to make health care safer & more effective & ensure hospitals achieve the best possible outcomes for all patients • How? Implement six targeted strategies proven to prevent adverse events • The initiative captured the attention of Canadian care providers, hospital administrators & others committed to improving patient safety. • On April 12, 2005, the Canadian campaign, Safer Healthcare Now!was created.

5. IHI / Safer Healthcare Now! Initiatives • Improved care for AMI • Prevent surgical site infections • Prevent central line infections • Prevent ventilator associated pneumonia • Deploy rapid response teams • Prevent adverse drug events: Medication reconciliation

6. Why Medication Reconciliation? • 2.9-16.6% of patients, in acute care hospitals, have experienced one or more adverse events • Adverse drug events are a leading cause of injury to hospitalized patients • Greater than 50% of all hospital medication errors occur at the interfaces of care • Admission to hospital • Transfer from one nursing unit to another • Transfer to step-down care • Discharge from hospital

7. Why Medication Reconciliation? • Frequency of medication discrepancies on a general medicine clinical teaching unit • 53.6% of patients had at least one unintended discrepancy • 38.6% of the discrepancies were judged to have the potential to cause moderate – severe discomfort or clinical deterioration • Most common error was an omission of a regularly used medication (46.4%) Arch Intern Med, 2005

8. SCH Patient: MP • 76 y.o. woman attending GDH admitted to CCU with bradycardia, then returned to GDH after receiving a pacemaker • CCU admission medication orders based on faxed hand-written list from community pharmacy • Errors: • Lescol 20mg written as Losec 20mg (Rx error) • Tramacet recorded as Tagamet (MD error) • On warfarin for AF: not ordered on admission or restarted on discharge • Sertraline & metformin put on hold in hospital but not reordered on discharge • Community pharmacist had no idea what this woman should or shouldn’t have in her blister pack

9. Medication Reconciliation – the solution? • Medication Reconciliation can: • Prevent omission of an at-home medication • Match in-house dose, frequency, and route with at-home usage • Ensure medications follow the patient from one care site to another

10. Why Now? • It’s the right thing to do…….. • Culture of safety: reduce medication errors & potential for patient harm • Key component of seamless care strategies • Saves time for physicians, nurses, and pharmacists in the long-term • Medication Reconciliation is a Canadian Council on Health Services Accreditation Standard (ROP) • In the SHR, Senior Leadership has endorsed Medication Reconciliation as a Regional Project of high priority

11. SHR Form and Process • A formal process of: • Obtaining ONE complete and accurate list of each patient’s current home medications (name, dosage, frequency, route) • Using the information obtained to write the admission orders • Referring back to the information obtained to write transfer and discharge orders

12. SHR Manual Medication Reconciliation Form and Process

13. Medication Reconciliation Form, page 2

14. Measuring Progress: Discrepancies • Undocumented intentional discrepancy: • physician made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented • Unintentional discrepancy: • physician unintentionally changed, added or omitted a medication the patient was taking prior to admission • Goal: • reduce number of discrepancies by 75%

15. SHR Baseline Data (5 Pilot Sites) • Undocumented Intentional Discrepancies: • 1.32 / patient • Goal: 0.33 / patient • Unintentional Discrepancies: • 1.28 / patient • Goal: 0.32 / patient

16. Are we making a difference? Baseline National: 1.1 Revise form PDSA 2 National: 0.6 PDSA 3 1 yr data check PDSA 4 Education PDSA 1 survey

17. Are we making a difference? Revise form PDSA 2 PDSA 3 National: 1.2 Baseline PDSA 4 1 yr data check Education National: 0.65 PDSA 1 survey

18. Comments on the Manual Form • It’s a blank form! • All medication information will have to be written in: • Will need to get the information from someone or somewhere. • How accurate is that information? • Potential for transcription errors when recording the medication history. • We need to get the medication history right for the rest of the process to work

19. The Next Step Using PIP to Generate an Admission Medication Reconciliation Form

20. PIP Auto-populated Medication Reconciliation Form

21. Has it made a difference? • SCH Emergency Admissions to General Medicine: • Undocumented Intentional Discrepancies • SHR Goal: 0.33 / patient • April 2007 (Manual Form): 0.1 • September 2007 (PIP Form): 0.2 • Unintentional Discrepancies • SHR Goal: 0.32 / patient • April 2007 (Manual Form): 3.1 • September 2007 (PIP Form): 1.3

22. Comments on the PIP Auto-populated Form • Gives medication name, strength, most recent fill date & prescriber’s name • A better starting point than a blank page, especially if a patient or caregiver cannot provide information. • Dose & interval still need to be clarified (& may be different than what was on the original prescription) • Still need to ask about medications not recorded on PIP • Avoids name & strength transcription errors for auto-populated medications

23. Conclusions • Medication Reconciliation does decrease medication errors • The Pharmaceutical Information Program auto-populated history and admission order form is a valuable tool for this initiative • Through collaboration we are advancing patient safety in Saskatchewan