Medication Reconciliation

Preventing Adverse Drug Events

One Patient at a Time

Today’s Schedule

• Medication Reconciliation Introduction– Break-out session #1: Preparing a Med History

• Best Possible Medication History – Break-out session #2: Interviewing a patient

• Pre-Admission Verification Form– Break-out session #3: Med Reconciliation process

• Verification Coding System & Medication Reconciliation Audit Tool – Break-out session #4: Medication Reconciliation

Audit

• Conclusion

Safer Healthcare Now!

• A campaign to enlist Canadian healthcare organizations in implementing six targeted interventions in patient care

• To improve the safety of our healthcare system in Canada

• A dynamic approach to quality improvement

National Collaborative Effort

• Medication Reconciliation is one of the Safer Healthcare Now Initiatives

1. Medication Reconciliation2. Improved Care for Acute Myocardial Infarction3. Prevention of Central-Line-Associated Infection 4. Rapid Response Teams 5. Prevention of Ventilator-Associated Pneumonia 6. Prevention of Surgical Site Infections

Medication Reconciliation

A formal process of obtaining a complete and accurate list of each

patient’s current medications

At Admission, Discharge

and at all other

Transitions in Care

Transitions in Care

Critical Care Unit

Operating Room Transitional

Care Unit

Inpatient Unit

Emergency Room

Rural Facility

Residential Facility

Home Community

Medication Reconciliation

• To prevent Adverse Drug Events (ADE’s) by implementing medication reconciliation in hospitals across Canada

• To eliminate medication discrepancies, at all interfaces of care, for all patients

• To ensure patients receive appropriate medications while hospitalized

• To improve communications at patient transfer points

Why Reconcile?

• Chart reviews have revealed over half of all hospital medication errors occur at the interfaces of care

• Medication errors are one of the leading causes of injury to hospital patients

The Case for Med Reconciliation

• 2004 Canadian Adverse Events Study– Drug and fluid related events were the

second most common type of procedure or event to which adverse events were related

• 2004 Study in Canadian Hospital– 23% incidence of adverse events in patients

discharged from an internal medicine service • 72% were medication related

The Case for Med Reconciliation• 2005 Canadian Study

– 151 General Medicine patients • Prescribed or receiving at least four medications• Not from an extended care facility

– 53.6% - Patients 1 Unintentional Discrepancy • 38.6% - Potential to cause moderate or severe discomfort or clinical deterioration • 46.4% - Omission of regularly used medication

Accreditation Responsibilities

• Canadian Council on Health Services Accreditation

– Patient Safety Goals & Required Organization Practices for 2005

• “Reconcile the patients’ medications upon admission, and with the involvement of the patient”

• “Reconcile medications with the patient at referral or transfer and communicate the patients’ medications to the next provider of service at referral or transfer to another setting, service, service provider, or level of care within or outside the organization”

Seamless Care

• “Desirable continuity of care delivered to a patient in the health care system across the spectrum of caregivers and their environment”

• “When moving between levels of care, patients’ drug information is not always transferred to all care providers in a timely fashion… consequently, the patient may not receive the most appropriate regimen for their condition of this seamless care process”

Medication Reconciliation is a key component of the Seamless Care

process

Medication Reconciliation Process

Easy as 1-2-3

1. Create the most complete and accurate list possible of all current medications

2. Use this list when writing medication orders

3. If using this process after admission orders have been written, reconcile and resolve any discrepancies

Key Benefits

• Prevent inadvertent omission of needed home medications

• Prevent failure to restart home medications following transfer and discharge

• Prevent duplicate therapy at discharge (result of brand/generic) combinations or formulary substitutions

• Prevent errors associated with orders having incorrect doses or dosage forms

Challenges

• No clear owner of med reconciliation process

• May be lack of knowledge and understanding by front line practitioners of the importance of this function

• No standard process to complete the collection of information

• No process to integrate the information obtained in the med history to the prescribing process

Potential Barriers

• Isn’t this physician/nurse/pharmacist job?

• Fear of change• Just another flavour of the week• Staff perceive this as additional work

– Reduce the number of caregivers collecting medication histories

– Build into usual work process

Medication Reconciliation

Best Possible Medication History(BPMH)

Best Possible Medication History

Definition

A medication history obtained by ahealthcare professional which includes

a thorough history of all regular

medication use (prescription and non-prescription)

Information Sources

• Patient – best source if patient competent

• Caregiver • Pharmanet • Prescription vials/Compliance packaging• Medication List • Pharmacy • Family Physician • MAR from previous institution

Med Rec Process at Admission

PREPARATION • Print Pharmanet record • Addressograph Home Medication

Reconciliation form • Determine if patient is capable of

providing med history

Patient Unable to Give Details

• Patient does not know name or details about medication – Obtain a detailed description of

medication • Dosage form (capsule, tablet)• Strength • Size • Shape • Color • Markings

Caregiver

• Good option if patient is not able to provide information

• Obtain information when caregiver is at hospital or call at home

• Helpful only if caregiver has knowledge of patient’s medication history and current use

Pharmanet Record

• Pharmanet record is a “Dispensing History” of past 15 months

• Limitations – Does not indicate medications active

or discontinued– May indicate compliance if consistent

dispensing patterns identified– Will not reflect physician-directed

changes made at doctor appointments

Prescription containers

• Acceptable – Prescription Vials – Pharmacy Blister packaging

• Questionable – Patient packaged cassettes

• Unacceptable – Evidence of mixing meds in one container – Unlabelled and Unidentifiable

medications

Medication List

• A good “supporting” resource if up-to-date

• Always a good idea to confirm accuracy of each item on list with patient

• May be outdated • Potential for transcription errors • Educate patients on the importance

of bringing a Medication List and/or Prescription Vials to the hospital

Pharmacy

• A good source to obtain Pharmanet record if unable to access Pharmanet

• Pharmacist may have additional supporting information – Number of refills left on a prescription – Compliance problems – Economic constraints – Allergy history – Therapeutic successes, failures

Family Physician

• Contact as a “last resort” to obtain information

• “Prescribing information”– Length of therapy – Indications – Distribution of samples

• May not be able to identify problems with compliance

Medication Administration Record

• If patient transferred from another institution – Long Term Care (LTC)– Rural hospital to Prince George

• Important to know if Best Possible Medication History (BPMH) was done at admission

• Important to record time of last doses

Interviewing Patients

• Time commitment – Goal 10min • Introduce yourself and explain

your role – Tell patient you would like to ask

him/her some questions about his/her medication use

– Ask if this is a good time • If not, schedule another time

Interviewing Patients

• Ask questions until you are confident all information is complete and reliable – Pursue unclear answers until they are clarified

• Use open-ended questions – What, how, why, when– Balance with yes/no questions

• Use nonbiased questions – Do not lead the patient into answering

something that may not be true

• Ask simple questions– Avoid using medical jargon

Interviewing Patients

• Prompt the patient to remember all medications– Prescriptions

• Patches, creams, eye drops, inhalers, sample medications

– Over-the-counter (OTC) medications – Herbal and other natural remedies – Vitamins and minerals – Non-drug therapy

• Use “head-to-toe” Review of Systems approach

Review of Systems

• HEENT– Nose, ear or eye drops – Analgesics used for headache or sinus pain– Dental products – Insomnia – Motion sickness – Smoking Cessation aids

• Respiratory tract – Antihistamines – Decongestants

Review of Systems

• GI/GU – Antacids – Antiflatulants – Antidiarrheals – Laxatives – Hemorrhoidal preparations – Vaginal antiinfectives

• Musculoskeletal – ASA – Anti-inflammatory agents – Acetaminophen or combination

Review of Systems

• Dermatological – Psoriatic/Seborrheic – Antiinfective – Analgesic topical preparation – Corns/callus pads or other foot care

• Hematological – Consider iron, B12, folic acid

• Overall/System-wide– Vitamins – Herbal – Homeopathic or other alternative healthcare

products

If Time Permits…

• Indication – This is the patient’s version of the indication

• Efficacy – Tell me how you know this medication is

working for you?

• Toxicity – Are there any problems that you are having

which you think may be caused by this medication?

– If patient says no, probe with a few of the most common side effects

If Time Permits…• Compliance

– How often do you take this medication?

– Try to verify if cost, dosing frequency, adverse effects, or personal beliefs may be an obstacle

• How do you feel your medications impact your life?• Tell me how you feel about medication use, in

general?

– Inquire about technique and maintenance of devices used to facilitate drug delivery or monitor drug therapy

• Inhalers and Spacers, BP monitors, Blood glucose monitors

Medication Reconciliation

Pre-Admission Medication Verification Form

Step 1

• True Allergy – Drug, food, additives, etc– Immunologically mediated reaction

• Type I – Type IV (see Coombs & Gell Classification)• Possible Allergy

– Vague/incomplete history of allergic reaction – Assume worst case scenario– Include “?”

• Intolerance – Side effects or adverse events – Predictable response

• N&V, GI upset

Allergies/Intolerances (include reaction) NKA

Penicillin – HivesPeanuts – Anaphylaxis Ibuprofen – GI upset Eggs? - Rxn Unknown

Step 2

• Medication dosing is frequently dependent on weight

• Document patient’s weight in kilograms (kg)– Actual

• Hospital weigh scale

– Estimate • Patient report • Nursing estimation

 

Wt: 76.8 kg  Actual Estimated

Step 3

• MEDICATION NAME – Document generic name - chemical name of drug

• If two chemical ingredients, list both– Avoid use of brand names

• Exception: multi-ingredient drugs – Sofracort – framycetin/gramicidin/dexamethasone

– Include full name • Erythromycin base, Erythromycin estolate

– Avoid use of abbreviations • Exception: ASA - Acetylsalicylic acid

Generic Name, Strength, & Formulation(Manufacturer or Brand Name)

1 Amoxicillin/Clavulanate

2 Diltiazem

 

Step 3

• STRENGTH

– Include specific information to clearly identify what product was dispensed to patient

– Example: • Prescription: Ramipril 10mg po daily • Medication Dispensed: Ramipril 5mg capsules

Generic Name, Strength, & Formulation(Manufacturer or Brand Name)

1 Amoxicillin/Clavulanate 250-62.5mg/5ml

2 Diltiazem 180mg

 

Step 3

• FORMULATION – Acceptable to use abbreviations

• Dosage forms – Susp- suspension – Liq – liquid – Tab or Cap – tablet or capsule – Inj – injectable

• Special formulations – EC – enteric coated – SR – sustained release

Generic Name, Strength, & Formulation(Manufacturer or Brand Name)

1 Amoxicillin/Clavulanate 250-62.5mg/5ml suspension

2 Diltiazem CD 180mg capsule

 

Step 3

• Prescription labels will include – Generic name PLUS

• Manufacturer OR Brand name OR Drug Identification Number (DIN)

• Additional Resources – Pharmacy or CPS – Drug Product Database http://www.hc-sc.gc.ca/hpb/drugs-dpd/

Generic Name, Strength, & Formulation(Manufacturer or Brand Name)

1 Amoxicillin/Clavulanate 250-62.5mg/5ml suspension

(GlaxoSmithKline or Clavulin-250F)

2 Diltiazem CD 180mg capsule

  (Biovail Pharm or Cardizem CD)

Step 3

• DOSE– Weight

• mg = milligram, g = gram, mcg = microgram – Do not use µg – confused with mg

– Volume • ml = millilitres, L = litres

– Miscellaneous • International Units

– Do not use IU – confused with IV or 10 (ten)• units

– Do not use U or u – confused as zero

Dose

 

500mg

 

180mg

Step 3

• Route– po – oral – ng – nasogastric – sc – subcutaneous – im – intramuscular – iv – intravenous

Route

 

PO

 

PO

Step 3

• FREQUENCY – daily

• Do not use q.d. or QD

– q2days• Do not use q.o.d. or QOD

– BID, TID, QID– q4h, q6h, q8h – 5 times daily

Frequency

 

TID

 

Daily

Step 3

• Duration– How long patient has taken med?

• wks, mths, days, doses…– If medication ordered for specific duration

• Indicate time taken in relation to prescribed duration– 2 doses of 14 days – 17 days of 6 weeks – 2 months of 6 months

Duration

 

4 of 10 days

 

4 years

Step 3

• Last dose (date/time)– Use 24hr hospital time– Month and day is adequate

Last Dose Date/Time

 1400hrMay 12

 0800hrMay 12

Step 3

• Indication/Comments – Indication as reported by patient if known– Adverse events experienced?– Physician directed patient to reduce dose

at last office visit – Non-compliance

Indication/Comment

Acute Sinusitis Non-compliance: taking bid

  AnginaExperiencing dizziness

Step 3

SPECIAL SITUATIONS• Documenting PRN’s

– Record frequency if there is a pattern – Include indication and frequency of episodes– Record in “Last Dose” column if medication

not taken in past week

Medication –Generic, Strength, & Formulation Dose Route Frequency Duration Last Dose Date/Time Indication/Comment

1

Ibuprofen 400mg tablets(Motrin)

400mg  POTID

PRN 3 yrs

0800hr May 12

headache1-2 episodes/month

2

Ranitidine 75mg tablets(Zantac)

 150mg

 PO

 DAILY PRN

 6 mths

Not taken in past week

 used occasionally to treat heartburn 6 episodes/mth

Step 3

SPECIAL SITUATIONS• Medications given in cycles

– Note date next dose due – Didrocal kit – note where patient is in 90 day cycle

Medication –Generic, Strength, & Formulation Dose Route Frequency Duration Last Dose Date/Time Indication/Comment

1

Cyanocobalamin 1000mcg/ml injectable (Sabex)

1000mcg  IM q3mths 1 yr

am Mar 21

Anemia Next dose due:Jun 21

2

Etidronate 400mg/Calcium Carbonate 1250mg (Didrocal)

1 tab    PO  Daily  3 mths0800hr May 12

 Osteoporosis 56 tablets left in 90

day kit

Step 4

• Moderate use = < 4 x 250ml cups of coffee/day • Heavy use = > 4 x 250ml cups of coffee/day

• Specify details of use below checklist if significant to note

• Class of stimulant medications called methylxanthines or xanthines– Theophylline – Chocolate theobromine – Caffeine

• Coffee 85mg/250ml (65-120mg) • Tea 40mg/250ml (20 – 110mg) • Cola 25mg/250ml (20-40mg) • Wake up 100mg caffeine tablets• Anacin, Excedrin, Midol, Tylenol #1

Caffeine No use Moderate Heavy Coffee 6 cups/day 

 

Step 4

• Alcohol effects the metabolism and effect of many medications

• Social – Drinks alcoholic beverages in moderation, chiefly when

socializing • Abuse

– Women or Elderly >65yrs: > 7 drinks* per week or > 3 drinks per occasion

– Men: > 14 drinks* per week or > 4 drinks per occasion *One drink =

» 12-oz bottle of beer (4.5 % alcohol) or» 5-oz glass of wine (12.9 % alcohol) or » 1.5-oz of 80-proof distilled spirits.

Alcohol No use Social Abuse 

Step 4

• Nicotine is a drug that can interact with other medications

• Former smoker – Note quit date

• Current – Note number of cigarettes or packs

smoked per day– Note if smoking cigars

Smoking Former NeverCurrent2 packs/day 

Step 4

• Recreational – Illicit drug use

• Marijuana, cocaine, crystal meth, heroine…– Prescription or non-prescription use

• Narcotics - Tylenol #1, Amphetamines, Benzodiazepines

• Interviewing Tips – A lot of people are using recreational drugs these days.

These drugs have a possibility of interfering with the medications you will be receiving in the hospital. Have you tried any? Are you currently using any?

Recreational No use Illicit Rx/OTC 

Step 4

• Influenza < 1yr • Pneumococcal < 5yr• Tetanus/Dipth <10yr• Hep B x 3 • Hep A x 2 • MMR x 2 • Meningococcal • Varicella x 2

Immunization Complete History Unavailable

Influenza <1yr Pneumococcal <5yr Tetanus/Dipth < 10yr Hep B x3

MMR x2 Meningococcal Varicella x2 Hep A x2

Step 5

• Indicate Source of Information – Ideal to interview patient

• Limitations if patient:– Confused – Does not speak English – Too ill to interview

– A good idea to document Family Physician, Pharmacy and Caregiver contact info in the event more information is needed later

Patient Pharmanet  Caregiver Jane Smith Ph: 987-4321

Prescription vials  Pharmacy Wal-Mart   Ph: 987-6543

Medication List MAR   Family Physician Dr. Green  Ph: 987-4444

Step 6

• Sign your name • Record date and time• Insert into patient chart

– beginning of Orders section

DOCUMENTED BY  

Alana Froese 1530hr May 12/06Nurse/Pharmacist/Technician Signature Date/Time

Physician Ordering Features • Physician reviews Pre-Admission

Medication list – Continues – Discontinues – Changes

• Verification Codes – Pharmaceutical Care Process

• Eight Drug Related Problems (DRP’s) • A quick way for physicians to indicate reasons for

intentional changes to therapy

• Physician signs and dates order

Order Processing Features • Unit clerk processes orders and

transcribes to MAR – uses yellow highlighter or initials in right

column to indicate order has been processed

• RN initials right column to indicate Unit Clerk has processed order and transcribed to MAR appropriately

• Check “Faxed to Pharmacy” to indicate order has been sent to Pharmacy

Final Touches

CONTINUE

DISCONTINUE

CHANGE

FLOOR  USE

1      

    4  

ST

ST

 

Faxed to Pharmacy Page __1____ of ___1____

Medication Reconciliation

Verification Coding System

Verification Code #1

• INDICATION 1.1 Patient has a diagnosed problem which

requires a drug therapy • New symptoms or indication revealed/presented

1.2 Preventative drug required • Taking a drug for valid indication, but this drug

causes side effects which require prophylactic therapy

1.3 Synergistic drug required • Requires synergistic drug therapy to potentiate

effect of current drug therapy

Verification Code #2

• NO INDICATION 2.1 No clear indication for drug use

• Improvement of disease state • Receiving drug chronically which was intended for

acute condition • Recreational use, addiction/dependence • Condition can be more appropriately treated by

non-drug therapy

2.2 Receiving a drug to treat an avoidable ADR

2.3 Inappropriate duplication of therapeutic class or active ingredient

Verification Code #3

• DOSE TOO LOW/DURATION TOO SHORT

3.1 Drug dose too low (sub-therapeutic)3.2 Dosage regime not frequent enough3.3 Duration of treatment too short

Verification Code #4

• DOSE TOO HIGH/DURATION TOO LONG

4.1 Drug dose too high (dose dependent toxicity)

4.2 Dosage regime too frequent 4.3 Duration of treatment too long

Verification Code #5

• WRONG DRUG 5.1 Inappropriate drug

• Inappropriate drug or dosage selection • More cost effective drug available • Drug therapy is known to be ineffective for this

indication• Drug therapy is effective for this indication, but not

effective in this patient for unknown reasons 5.2 Inappropriate drug form

• Cannot take the drug product (swallow, taste, administration)

5.3 Contraindication for drug (incl. pregnancy/ breastfeeding)

Verification Code #6

• NON-COMPLIANCE 6.1 Patient is not compliant

• Drug underused, overused or abused • Patient has difficulties reading/understanding

6.2 Drug not taken/administered at all • Patient unable to use drug/form as directed • Patient unwilling to carry financial costs • Prescribed drug not available

6.3 Wrong drug taken/administered • Prescribing error• Dispensing error (wrong drug or dose dispensed)• Administration error (by patient/caregivers)

Verification Code #7

• ADVERSE EVENT

7.1 Side effect suffered at a therapeutic dose (non-allergic)

7.2 Side effect suffered at a therapeutic dose (allergic)

7.3 Toxic effects suffered

Verification Code #8

• DRUG INTERACTION

8.1 Potential or actual Drug/Drug interaction

8.2 Potential or actual Drug/Food interaction

8.3 Potential or actual Drug/Laboratory interaction

Medication Reconciliation

Medication Reconciliation Audit Tool

Purpose

To collect data and measure reduction in “discrepancies”

between home medication list and admission orders

Discrepancies

• Intentional – Physician has made an intentional choice to add,

change, discontinue a medication– Choice is clearly documented

• Undocumented Intentional – Physician has made an intentional choice to add,

change, discontinue a medication– Choice is not clearly documented

• Unintentional – Physician unintentionally changed, added, or omitted

a medication the patient was taking prior to admission

Measurements

• Mean # Undocumented Intentional

Discrepancies = # of undocumented discrepancies

# of patients

• Goal: Reduce the rate of undocumented intentional discrepancies at admission by 75% in 1 year

Measurements

• Mean # Unintentional Discrepancies = # of unintentional discrepancies

# of patients

• Goal: Reduce the rate of unintentional discrepancies at admission by 75% in 1 year

Measurements

• Medication Reconciliation Success Index =

# of NO discrepancies + # of documented intentional discrepancies X100

# of NO discrepancies + total # of ALL discrepancies

• Goal: To increase the effectiveness of the medication admission reconciliation process over time

Recording • Document details of discrepancies:

– Med Reconciliation form

– Patient’s Hospital record • Indicate if OTC medication

– Definition: A medication not prescribed by a physician– OTC medication discrepancies will not be reported to

National Safer Healthcare Now campaign

• Resolve or transfer to pharmacist for follow up

• Record if discrepancies were resolved on Med Reconciliation form • Recorder to sign form

Recording • Record Admission Date/Time

– Defined as time patient was designated to be admitted to hospital

– Not Emergency admission time

• Reconciliation Date/Time– Perform within 24 hours after admission

• Implementation Stage – Baseline – before changes to process – Early Implementation – after changes to process made

by a select team – Full Implementation – when medication reconciliation

process is integrated by all staff on designated ward

Investigator’s Role

• Lead investigator will collect audit forms

• Will be responsible for: – Completing Discrepancy Totals on forms– Calculating & reporting measurements

to National Safer Healthcare Now Campaign

– Reporting findings internally

Medication Reconciliation

Coming to a Hospital Near You!

NH-Wide Implementation

• Initial testing sites – Prince George – Quesnel – Dawson Creek– Burns Lake

• Goal: To standardize the Medication Reconciliation process

• Continue to spread implementation to all healthcare settings in Northern Health

Just Do It!

PUT THEORY INTO PRACTICE

ESTABLISH STANDARD PROCESS

PROMOTE MEDICATION SAFETY

BEGIN IMPLEMENTATION TODAY

Leading the Way

• You are the Trail Blazers – Role Models, Mentors, Educators – Promote cultural change – Lead by Example– Collaborate – Demand Excellence – Do not Compromise

Building it into the Process “The names of the patients whose lives we save

can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been.” Donald M. Berwick, MD, MPP

President and CEO Institute for Healthcare Improvement

“Accomplishing the Impossible…

…means only that the boss will add it to your regular duties” – Doug Larson