Medication Reconciliation in Long Term Care Ontario Node

1. Medication Reconciliationin Long Term CareOntario Node Margaret Colquhoun Olavo Fernandes SHN Intervention Lead National MedRec Faculty Member January 2009

2. ISMP Canadawww.ismp-canada.org  To identify risks in medication use systems, recommend optimal system safeguards and advance safe medication practices. Works to advance safe medication use.

3. What is Medication Reconciliation? A process in which medications are compared at interfaces of care: Acute to Long Term Care Discrepancies are identified and reconciled Intervention minimizes patient harm from unintended discrepancies

5. Medication Reconciliation in LTC A formal process of: At admission, creating a complete and list of resident�s pre-admission medications � including name, dosage, frequency and route (BPMH). Using the BPMH to create admission orders or comparing the list against the resident�s admission orders, identifying and bringing any discrepancies to the attention of the prescriber for resolution. Any resulting changes in orders are documented and communicated to the relevant providers of care and resident or family member wherever possible.

7. Currently�.. For LTC patients, information transfer is inconsistent, not standardized and in many admissions is sorely lacking Acute care > active rehab > LTC > Community (home) Community > homecare>LTC

8. The Problem Incomplete/inaccurate medication information is reflected in growing number of LTC studies. Alberta 2007 survey: 75% medication information was NOT legible/complete 90% information was NOT available to tell prescribed medications appropriate for diagnoses. 40% medication information DID NOT arrive the same day as the resident�s admission. (1) (1) Earnshaw, K et. al. Perspectives of Alberta Nurses and Pharmacists on Medication Information Received. July 29, 2007

9. The Problem 2004 study(2) �incidence of ADEs caused by medication changes at transfer between facilities was 20%. Most on transfer from acute to LTC Incomplete/inaccurate communication a factor

10. True LTC Medication Reconciliation Patient stories� Transplant rejection drugs not ordered on admission (>48hr delay in restarting) Glaucoma meds missed for 14 days #1 Kidney transplant patient admitted and rejection drugs not continued for >48hrs. Med rec in 24hrs would have solved this quicker. Potential for harm very real and very great. #2 Patient transferred from RGH to PH under care of family physician. Med rec process identified pts glaucoma eye drops not ordered or given for 2 weeks. Potential for harm � real. #3 Hydromorphone 3mg q12h at home transcribed as 30mg q12h on admission. Pharmacy processed orders. Patient was admitted on a Friday afternoon and was given one dose Friday night and another Saturday am. Family arrived Saturday and took patient out on pass and called in a few hours later stating the patient had become lethargic with decreased responsiveness. Family was directed to take patient to ER for assessment � observed for several hours and back to normal. Patient taken back to LTC facility and received Saturday pm dose and Sunday am dose � once again unresponsive and then the problem was found. #4 Elderly patient was admitted with newly diagnosed afib and had simple hospital course saw rate control calcium channel blocker therapy changed from amlodipine to diltiazem. Patient not informed of change and went home and took both. Readmitted 3 days later due to severe bradycardia and nearly required pacemaker.#1 Kidney transplant patient admitted and rejection drugs not continued for >48hrs. Med rec in 24hrs would have solved this quicker. Potential for harm very real and very great. #2 Patient transferred from RGH to PH under care of family physician. Med rec process identified pts glaucoma eye drops not ordered or given for 2 weeks. Potential for harm � real. #3 Hydromorphone 3mg q12h at home transcribed as 30mg q12h on admission. Pharmacy processed orders. Patient was admitted on a Friday afternoon and was given one dose Friday night and another Saturday am. Family arrived Saturday and took patient out on pass and called in a few hours later stating the patient had become lethargic with decreased responsiveness. Family was directed to take patient to ER for assessment � observed for several hours and back to normal. Patient taken back to LTC facility and received Saturday pm dose and Sunday am dose � once again unresponsive and then the problem was found. #4 Elderly patient was admitted with newly diagnosed afib and had simple hospital course saw rate control calcium channel blocker therapy changed from amlodipine to diltiazem. Patient not informed of change and went home and took both. Readmitted 3 days later due to severe bradycardia and nearly required pacemaker.

11. True LTC Patient Story� Patient admitted to acute care for investigation of recent onset of jaundice Levothyroxine daily not ordered � missed for 3 weeks Returned to LTC with symptoms of hypothyroidism

12. What�s so different about LTC? Lengthy stays Treatment includes many medications Average 9.8 meds, up to 12.7 meds including prn Care by fewer professional staff Limited on-site pharmacist time Variable availability of physicians Fewer admissions

13. What is Similar about Medication Reconciliation in LTC? The process � although fewer interfaces The potential results

14. Terminology Best Possible Medication History (BPMH) - A current medication history includes all regular medication use Requires training Uses multiple sources of info Is compared to admission orders to identify discrepancies

16. Terminology Undocumented Intentional discrepancy is one in which the prescriber has made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented. Unintentional discrepancy is one in which the prescriber unintentionally changed, added or omitted a medication the resident was taking prior to admission.

17. Terminology Most Current Medication List � The most recent list of medications (name of medication, dose, route and frequency) currently taken by the resident � Used for medication reconciliation at discharge

18. Core Measures Mean number of UNDOCUMENTED INTENTIONAL Discrepancies (Documentation Accuracy) Target: Reduce Mean number of UNINTENTIONAL Discrepancies (Medication Error) Target: Reduce Percentage of Residents Reconciled upon admission Target: Increase to 100% of residents at admission.

19. Where will Medication Reconciliation Occur At Admission from: Home Acute care hospital Complex and continuing care facility Community/Assisted Living Rehab/Complex Continuing Care At Transfer from: Another long term care facility Another unit within the facility

21. Keys to Implementation Secure leadership commitment & involvement Create a project plan (map current process) Educate staff: Why medication reconciliation? How to reconcile BPMH training Develop and test new process(es) Embed process so that it becomes �the way you do things� Measure & sustain the improvements you have made Spread to other areas / populations

22. Keys to Implementation cont�d Proactive vs. reactive Different disciplines Institution specific NOT about a form Engage patient & family

23. Supports Getting Started Kit (GSK ) MedsCheck Ontario Node ISMP Canada National calls Community of Practice � LTC section/tools National Learning Series

24. Getting Started Kit:Medication Reconciliation in Long-Term Care Step-by-step guide to the process Model for Improvement Tools and Tips Samples

25. MedsCheckOntario Ministry of Health and Long-Term Care Funded by MOHLTC One-on-one 30 minute appointment with the community pharmacist Reviews all the patient�s medications (prescribed and OTC) Helps patients better understand their medication therapy and ensure that medications are taken as prescribed.

26. Who is eligible for a MedsCheck? All Ontarians are eligible Once per year No additional cost to client Provided they are taking 3 or more medications for a chronic condition. Community Pharmacist is reimbursed for their professional services.

27. MedsCheck Personal Medication Record

28. What�s a MedsCheck Follow-up? MedsCheck Follow-up is a program for patients who may benefit from additional MedsChecks during the annual timeframe. There is no limit to the number of Medscheck Follow-ups provided they meet the following criteria: A planned hospital admission (e.g. elective surgery) A physician or registered nurse in the extended class (RN[EC]) request A recent discharge from hospital (within 2 weeks)

29. Communities of Practice

30. Picture Tool DON�T FORGET THESE TYPES OF MEDICATIONS �

31. SHN Website � Critical Success Factors: Education Standardize material Make use of �teaching� moments ON SLIDE 26, the 3rd critiical success factor is education Like communication it is ongoing What helps education is to standardize material � nurse leaders suggested we produce an educational video to show new staff. A lot of our unintentional discrepancies were coming from our residents being tasked with Rx home meds postop and being unaware of how to use the BPMH. Our chief of surgery suggested this video becomes part of the VIHA resident�s educational package Educational moments = not all has to be formal, always �out there� talking the talkON SLIDE 26, the 3rd critiical success factor is education Like communication it is ongoing What helps education is to standardize material � nurse leaders suggested we produce an educational video to show new staff. A lot of our unintentional discrepancies were coming from our residents being tasked with Rx home meds postop and being unaware of how to use the BPMH. Our chief of surgery suggested this video becomes part of the VIHA resident�s educational package Educational moments = not all has to be formal, always �out there� talking the talk

32. Acute Care Learning Data, results, stories Training One size does not fit all Requires resident/family participation Use different health disciplines appropriately Takes commitment and leadership!! Is the right thing to do