You are the Answer:Nurses Save Patients with Medication Reconciliation

Karla Davis, Mary Hanna, Alicia Hegwood, Lisa Sims

1999 Institute of Medicine (IOM) Report1999 Institute of Medicine (IOM) ReportTo Err is Human.

• Medication errors occur frequently and most are due Medication errors occur frequently and most are due to process failuresto process failures

• 2009 TJC- National Patient Safety Goal:• Accurately and completely reconcile medications across

the continuum of care. • When a patient leaves the organization’s care a complete

and reconciled list of the patient’s medications is provided:• Directly to the Patient/Family• Explained to the Patient/Family.

Research Question

• Have medication errors decreased during the transition from acute care to home, in the adult population, since initiation of the requirements for medication reconciliation by The Joint Commission 2005 National Patient Safety Goals?

Case Study 1

• 49 YO female; IDDM, kidney transplant, Breast CA with spinal metastasis

• Admitted for vertebroplasty & kyphoplasty• 9/3 – DC home• 9/6 – Presented to another hospital with fever• MR noted low grade fevers, BC + for Gram +

cocci / Gram - rods• 9/8 – Transferred to primary hospital• Febrile; MD failed to continue Gram – AB

coverage

Critical Thinking

• Would medication reconciliation have avoided this error from occurring? If so, how?

• What is the process at your organization for external transfer patients and would it have been able to prevent a similar event from occurring?

• What disciplines are expected to reconcile medications for external transfer patients at your organization?

Always Remember

• External transfer is a vulnerable process for medication error

• You are the patient’s last line of defense

Case Study 2

• 87 YO male: PHH - CAD, HF, Afib, HTN, severe MR• 4/17 – Anemic- Colonoscopy/EGD to R/O GI bleed

• Warfarin held for one week as prep for procedure• Discharge- No ASA/NSAIDS for 10 days post-procedure

• 4/19 – F/U with cardiologist• 4/26 – Missed Warfarin Clinic• 4/31 – Admitted with left side weakness, slurred speech, AMS

• CT negative, INR 1.2• 5/01 - Repeat CT positive for ischemic CVA

Critical Thinking Questions

• At what point in the hospital stay was medication reconciliation done?

• When is medication reconciliation required by Joint Commission?

• What could have been done differently to avoid this mediation error from occurring?

And The Answers Are…

• Medication Reconciliation- ALL transitions of care

• Updated Home Medication Record• Patient • Next provider of care

• Counsel patients on changes at discharge• Increase compliance• Decrease harm

The Case for Medication Reconciliation

• Adverse events after discharge to home:

• 19% of US patients

• 23% of Canadian patients

• In 2003, over 38 million Americans were discharged from hospitals

Literature Review

• Key words:• “medication reconciliation”, “discharge”, “medicine

reconcile”, and “patient safety”

• Databases accessed:• CINAHL • ProQuest • PubMed • Cochrane• HealthSource: Nursing & Academic Edition

• Cochrane Reviews:• No Systematic Reviews• 3 Clinical Trials

Levels of Evidence

Level 1ASystematic Review

Level 1BRandomized Control Trials

Level IICohort Studies

Level IIICase- Control Studies

Level IVCase Series, Case Scenarios

Level VEditorials, Expert Opinion

Bell, et al.

• Level of Evidence- Level IV

• Mode- Ex post facto

• Setting

• Population

• Sample

• Findings

Varkey, et al.

• Level of Evidence- Level III• Mode- Correlation quantitative

quasiexperimental• Setting • Population• Findings

Holzmueller, et al.

• Level of Evidence- Level III

• Correlation quantitative quasiexperimental

• Setting

• Population

• Findings

Vira, et al.

• Level of Evidence- Level IV

• Mode- Prospective, descriptive, nonexperimental

• Setting • Population

• Findings

Ethical Issues

• 3 Self-Executed Studies

• 1 Unknown Outside Agency

Findings

• Positive relationship exists between MR processes & medication errors:• Risk for morbidity-20% to 25% of chronic life-

sustaining medications unintentionally discontinued (Bell, et al.)

• Implementation of MR process:• Post MR implementation the error rate improved

42% to 0.74 errors per patient (Holzmueller, et al.)

Findings

• Preliminary MR process (Varkey, et al.) • Significant number of medication errors were noted • Medication errors increased as medications at

discharge increased• MR process reduced discrepancies by 50% and

significantly decreased the severity of ADE• Vira, et al. reported

• 51% patients required physician intervention• 9% pts had =or> 10 clinically important dc variances

Best Practice

• Three Step Process

• Verification

• Clarification• Reconciliation

Best Practice Guidelines

• Four guidelines with complete toolkits: • Health Care Association of New Jersey, 2006• 5 Million Lives Campaign, IHI, 2008• Legacy Health System, 2008• The Carolinas Center for Medical Excellence,

2005• All Included:

• Role Delineation• References

Fax Cover Sheet

 

Legacy Health System [Click here and type location] [Click here and type department] [Click here and type address] [Click here and type city, state, zip code]

Fax Date:

To: From:

Fax No: Phone No:

CC: Pages:

Subject: Medication Reconciliation Home Medication List

Urgent For Review Please Comment Please Reply Please Recycle

Comments:

The following pages contain a list of discharge medications for one of your clinic patients. Your patient was recently admitted to (or entered into) Legacy Health System. This is his/her current list of medications to be taken upon discharge/release. The Joint Commission requires all accredited hospitals to send this information to the patient’s primary care provider (or next provider of service) upon discharge.

Challenges

• Change fatigue

• “Just another task”

• No plug and play

• High levels of continuum of care

• Electronic health records not connected

• Source of information- not knowledgeable

• MR is expensive(Thompson, K. K., 2007)

Recommendations

• Standardize Discharge Medication Reconciliation Standardize Discharge Medication Reconciliation Process:Process:• Flow ChartFlow Chart• Medication Reconciliation Form at discharge- Medication Reconciliation Form at discharge-

include medications to be STOPPED.include medications to be STOPPED.• Discharge Medication List Discharge Medication List

• Sent to primary care provider or next level of care Sent to primary care provider or next level of care with verification of receiving document.with verification of receiving document.

Conclusion

• Complexity slows and frustrates the MR process

• Make process simple as possible

• Nursing owns the process

Questions???

References:

• 5 Million Lives Campaign. (2008). Getting started kit: Prevent adverse drug events (medication reconciliation) how-to guide. Cambridge, MA: Institute for Healthcare Improvement. Retrieved November 16, 2008, from http://www.ihi.org/NR/rdonlyres/98096387-C903-4252-8276- 5BFC181C0C7F/0/ADEHowtoGuide.doc.

Bell, C. M., Rahimi- Darabad, P., & Orner, A. I. (2006). Discontinuity of chronic medications in patients discharged from the intensive care unit. Journal of General Internal Medicine, 21(6), 937-941. Retrieved September 1, 2008, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1831608.

Best Practice Committee of the Health Care Association of New Jersey. (2006). Health Care Association of New Jersey Medication Management Guideline. Retrieved November 10, 2008, from http://www.hcanj.org/docs/hcanjbp_medmgmt.pdf.

Delate, T., Chester, E. A., Stubbings, T. W., & Barnes, C. A. (2008) Clinical outcomes of home-based medication reconciliation program after discharge from a skilled nursing facility. Pharmacotherapy, 28, 444-452. Aurora, CO: Department of Pharmacy, Kaiser Permanente Colorado. Retrieved November 19, 2008, from Cochrane database.

Finkleman, A. W. (2006). Leadership and management in nursing. Upper Saddle River, NJ: Prentice Hall.

Greenwald, J. L., Denham, C. R., & Jack, B. W. (2007). The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process. Journal of patient safety: The official publication of National Patient Safety Foundation, 3(2), 97-106. Retrieved October 9, 2008, from Auburn University Montgomery - Interlibrary Loan. Holzmueller, C. G., Hobson, D., Berenholtz, S. M., Feroli, E. R., et al. (2006). Medication reconciliation: Are we meeting the requirements? Journal of Clinical Outcomes Management, 13(8), 441-444. Located on CINAHL with Full Text. Retrieved October 10, 2008, from Auburn University Montgomery Library – Interlibrary Loan.

Institute of Medicine. (2000). Institute of Medicine. (2000). To err is human: Building a safer health system. To err is human: Building a safer health system. Retrieved November 19, 2008, from Retrieved November 19, 2008, from http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf

Legacy Health System, (2008). Flowchart for medication reconciliation at discharge. Retrieved November 8, 2008, from http://www.legacyhealth.org/body.cfm?id=1878http://www.legacyhealth.org/documents/Medication%20Reconciliation/Flowcharts/EchartDischarge.pdf.Manning, D. M., O'Meara, J. G., Williams, A. R., Rahman, A., Myhre, D., Tammel, K. J., & Carter, L.C. (2007). 3D: A tool for medication discharge education. Quality & Safety in Health Care, 16, 71-76. Rochester, MN: Department of Medicine, Mayo Clinic. Retrieved November 19, 2008, from Cochrane database.

References:

•Manno, M. S., & Hayes, D. D. (2006). Best practice interventions: How medication reconciliation saves lives. Nursing 2006, March. Retrieved November 10, 2008, from CINAHL with Full Text http://aumnicat.aum.edu:2055/ehost/pdf?vid=5&hid=3&sid=f1c7dec3-588d-40e0-859d-6a11bb7f2d08%40sessionmgr8.

Nickerson, A., MacKinnon, N. J., Roberts, N., & Saulnier, L. (2005). Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthcare Quarterly (Toronto, Ont.), 8, 65-72. Moncton, NB: South-East Regional Health Authority. Retrieved November 19, 2008, from Cochrane database.

The Joint Commission. (2008). The Joint Commission announces 2009 National Patient Safety. Retrieved November 10, 2008, Retrieved November 10, 2008, from http://www.jointcommission.org/NR/rdonlyres/40A7233C-C4F7-4680-9861-80CDFD5F62C6/0/09_NPSG_HAP_gp.pdffrom http://www.jointcommission.org/NR/rdonlyres/40A7233C-C4F7-4680-9861-80CDFD5F62C6/0/09_NPSG_HAP_gp.pdf

The Joint Commission. (2005). 2005 Hospitals’ National Patient Safety Goals. Retrieved November 10, 2008, from The Joint Commission. (2005). 2005 Hospitals’ National Patient Safety Goals. Retrieved November 10, 2008, from http://www.jointcommission.org/NR/rdonlyres/CA814047-805D-4143-AD3C-0C1944C49E75/0/05_hap_npsg.pdfhttp://www.jointcommission.org/NR/rdonlyres/CA814047-805D-4143-AD3C-0C1944C49E75/0/05_hap_npsg.pdf

Thompson, K. K. (2007). Medication reconciliation: Challenges and opportunities. American Journal Health Systems – Pharmacists, 64(9), 1912. Retrieved August 30, 2008, from ProQuest. Titler, M. (2006). itler, M. (2006). Developing an evidence-based practice.Developing an evidence-based practice. Nursing research: Methods and critical appraisal for evidence-based Nursing research: Methods and critical appraisal for evidence-based practice, Eds. LoBiondo-Wood, G. & Haber, J. 6practice, Eds. LoBiondo-Wood, G. & Haber, J. 6thth ed., Chap. 16, p. 450. Mosby-Elsevier, St. Louis, MO. ed., Chap. 16, p. 450. Mosby-Elsevier, St. Louis, MO.

Tsilimingras, D & Bates, D. W. (2008).Performance improvement: Addressing postdischarge adverse events: A neglected area. Joint Commission on Accrediation of Healthcare Organizations, 34(2), 85-97. Retrieved October 08, 2008, from Interlibrary Loan. Varkey, P., Cunningham, J., O'Meare, J., Bonacci, R., Desai, N., & Sheeler, R. (2007). Multidisciplinary approach to inpatient medication reconciliation in an academic setting. American Journal of Health-Systems and Pharmacology, 64, 1-12. Retrieved August 30, 2008, from CINAHL with Full Text.

Vira, T., Colquhoun, & Etchells, E. (2006). Reconcilable differences: Correcting medication errors at hospital admission and discharge. Quality and Safety in Health Care, 15, 122-126 Retrieved August 30, 2008, from PubMed Central.