Medication Reconciliation at Discharge: Challenges and Best Practices

1. Medication Reconciliation at Discharge:Challenges and Best Practices Jeannell Mansur, Pharm.D., FASHP Practice Leader, Medication Safety Joint Commission Resources

2. 2 Stories from the field� Communication failure around medication reconciliation The hospital that thought their process was in place

3. 3 Why Is Medication Reconciliation Important? Most frequently occurring type of medical error: Medication errors Most frequently cited category of root causes for serious adverse events: Ineffective communication Most vulnerable parts of a process: Links between the steps (the �hand-offs�)

4. 4 How do We Justify the Need for Medication Reconciliation? Prescribing errors known to occur when there is incomplete information about the patient 27% of hospital prescribing errors attributed to incomplete medication history on admission Reference: Dobrzanski s, Br J Clin Govern 2002; 7: 187-93 Medication discrepancies can lead to harm: 22% - in hospital 59% - after discharge Reference: Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C and Noskin GA. Am J Health-Syst Pharm. 2004; 61:1689-95

5. 5 Prevalence and Nature of Discrepancies at Discharge Study: focus on discrepancies between discharge medication list and prescriptions issued Rate of actual or potential discrepancy: 70.7% Most frequent type: Incomplete Omission Wong et al. Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies Ann Pharmacother.2008 42(10):1373-1379

6. 6 What is the Current State of Medication Reconciliation? Different models exist Final accountability is often ill defined Not implemented consistently in all areas throughout the organization

7. 7 Also in the Current State�. Providers are retrieving medication history from sources other than patient Discrepancies exist across documentation, prescription bottles, and patient�s actual use of medications 70% of drug-related problems discovered only through a patient interview Even computerized models are manual

8. 8 Medication Reconciliation: Why are Organizations Having Such Challenges? Processes are poorly defined or not defined for all required areas Overly complex processes Not embedded in routine workflow Responsible parties are not identified; with backup resources, as required

9. 9 Specific Goals for Discharge Develop a list of medications the patient should take at home Reconcile with the home medication list Clear communication regarding what is new, what should be stopped and what will continue Communication to next provider Maintaining an updated copy of the list

10. 10 Refining the Process  Begin the process Assess the process Staff surveys Audits Closed chart Tracer audits

11. Northwestern Memorial Hospital MATCH (Medications at Transitions and Clinical Hand-offs) Program Funded by AHRQ Grant

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15. 15 Using Electronic Medication Reconciliation Tools One record Decreases potential for transcription errors Can provide a legible list

16. 16 Discharge Medication List Template from an EMR

17. 17 Patient Discharge is a High Risk Process! Discharge period Chaotic Patient concerns Limited attention to details Patients at highest risk for preventable adverse events post discharge When to involve your pharmacist

18. 18 How are You Performing: Medication Reconciliation at Discharge Accountability for Performing the Reconciliation Who reconciles Who communicates Information that is Clear and not Subject to Mis-interpretation Optimal design of the discharge medication list Use of lay language Communication skills to enhance understanding

19. 19 How are You Performing: Medication Reconciliation at Discharge How are you tracking? Consistency Does each patient discharged receive a home medication list Does each patient discharged receive counseling Quality Accuracy between the Medical Record, the Discharge Medication List and the Prescriptions written How well does patient understand?

20. 20 Recommended Strategies to Improve Performance Examine your process Is it valid? Is it followed? Where are failure points What is contributing to these? Are you addressing these?

21. 21 Recommended Strategies to Improve Performance Multidisciplinary involvement A Synchronized Process

22. 22 Questions