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…a shared responsibility for health care
How Medication Reconciliation Supports
Patient Safety15 September 2007
Jane Richardson, BSP, PhD, FCSHPCoordinator, Clinical Pharmacy ServicesTeam Lead, SCH Med Rec Pilot Site
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.
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)
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.
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
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
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
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
Medication Reconciliation – the solution?
• Medication Reconciliation can:1. Prevent omission of an at-home
medication2. Match in-house dose, frequency, and
route with at-home usage3. Ensure medications follow the patient
from one care site to another
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
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
SHR ManualMedication Reconciliation
Form and Process
Medication ReconciliationForm, page 2
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%
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
1.0 Mean Number of Undocumented Intentional Discrepancies
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
Nov 200
5
Jan
2006
Mar
2006
May
2006
Jul 2
006
Sep 2
006
Nov 200
6
Jan
2007
Mar
2007
May
2007
Jul 2
007
Sep 2
007
Nov 200
7
Jan
2008
Mar
2008
May
2008
Month
Mea
n
Actual Goal
Are we making a difference?
Baseline
PDSA 1survey
PDSA 2
Edu
catio
n
PDSA 3
PDSA 4
Reviseform
1 yr datacheck
National: 1.1
National: 0.6
2.0 Mean Number of Unintentional Discrepancies
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
Nov 2
005
Dec 2
005
Jan
2006
Feb 2
006
Mar
200
6
Apr 2
006
May
2006
Jun
2006
Jul 2
006
Aug 2
006
Sep 2
006
Oct 20
06
Nov 2
006
Dec 2
006
Jan
2007
Feb 2
007
Mar
200
7
Apr 2
007
May
2007
Jun
2007
Jul 2
007
Aug 2
007
Sep 2
007
Oct 20
07
Nov 2
007
Dec 2
007
Jan
2008
Feb 2
008
Mar
200
8
Apr 2
008
May
2008
Jun
2008
Month
Me
an
Actual Goal
Are we making a difference?
Baseline
PDSA 1survey
PDSA 2
Education
PDSA 3
PDSA 4
Reviseform
1 yr datacheck
National: 1.2
National: 0.65
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
The Next Step
Using PIP to Generate
an Admission
Medication Reconciliation Form
PIP Auto-populatedMedication
ReconciliationForm
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
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
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