A Layered Learning Medication Reconciliation Program

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1 A Layered Learning Medication Reconciliation Program Brittany Bates, PharmD, BCPS Clinical Pharmacist, Lima Memorial Health System Clinical Assistant Professor, Ohio Northern University Jana Randolph, PharmD Candidate 2018 Ohio Northern University

2 Objectives Pharmacist Learning Objectives: Describe a medication reconciliation independent study course utilizing pharmacy students in an institutional setting Review drug classes and patient factors associated with a high risk of medication reconciliation errors Technician Learning Objective: Review drug classes and patient factors associated with a high risk of medication reconciliation errors

3 Medication Reconciliation Definition: the process of preventing unintended discrepancies in medication profiles by reviewing each patient s full medication regimen at every care transition, including admission, transfer, and discharge Strategy for minimizing adverse drug events (ADEs) In an observational study, errors in medication history were the most common cause of unintended medication discrepancies (186/257, 72%) Included in The Joint Commission s National Patient Safety Goals Agency for Healthcare Research and Quality [Internet] The Joint Commission [Internet] Pippins JR, et al. J Gen Intern Med. 2008

4 Impact of ADEs Retrospective study in Australia found a 5.5% risk of experiencing an adverse drug reaction (ADR) while hospitalized In a meta-analysis of 24,128 patients, 1.6% of inpatients experienced a preventable adverse drug reaction 45% of inpatient ADRs were preventable In a retrospective analysis, among 596 patients with ADEs, estimated direct cost per patient: $ Hauck K, Zhao X. Med Care Hakkarainen KM, et al. PLoS One Gyllensten H, et al. PLoS One

5 Who Can Perform Medication Reconciliation Nurses Physicians Pharmacists Pharmacy technicians Students One study found that pharmacy students identified significantly more preadmission medications per patient than did nurses or physicians Lancaster JW, Grgurich PE. Am J Pharm Educ

6 Layered Learning A core group of clinicians leading a team which may include pharmacy residents and students Advantages include: Supporting Practice Advancement Initiatives (PAI) Partnerships between institutions and pharmacy schools may result in the success of each party Students are low-cost resources Improved patient satisfaction Pinelli NR et al. Am J Health-Syst Pharm Soric MM et al. Am J Health-Syst Pharm 2016.

7 Layered Learning: The LMHS Med Rec Model Pharmacists Shared Faculty Member (course coordinator) Pharmacy Residents, Staff Pharmacists Students (P4-P5 year) Students (P2-P3 year)

8 Medication Reconciliation Course Started in Fall 2015 as a semester-long independent study course at Ohio Northern University (0-6 program) Fall Semester: P2 and P4 students Spring Semester: P3 and P5 students Why? Layered Learning Additional hands-on experience with patients Assist LMHS in correctly identifying home medications and preventing ADRs

9 Medication Reconciliation Course Week 1: Overview/Background on Course and Med Rec Weeks 2-4: On-site Training Students paired with a pharmacist, resident, and/or APPE student Computer training Shadow ER med rec technician Putting it all together Weeks 5 and After Independent portion begins Pharmacists available 24/7 if questions arise

10 Medication Reconciliation Course Expectations of students: A pair of students assigned each weekday Spend 1-3 hours at the site, typically in the afternoon/evening Identify patients, complete medication history, and update home medication list within the EMR Document interventions in EMR and give forms to pharmacist for review Urgent changes addressed by evening pharmacist(s) Non-urgent changes addressed by clinical pharmacist the following day

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12 High-Risk Disease State Home Medication Review DATA COLLECTED DURING SPRING SEMESTER 2017

13 Patient Demographics Location of admission Admission Location n (%) Emergency department 51 (68.9%) Transfer from another facility 12 (16.2%) Direct admission 7 (9.5%) Internal transfer 4 (5.4%) Person who gathered initial medication history Title n (%) Pharmacy technician 44 (59.5%) Other hospital staff 27 (36.5%) APPE student 1 (1.4%) Pharmacy intern 1 (1.4%) Unknown 1 (1.4%)

14 Number of Discrepancies Identified Students identified at least one error in home medication list in 50 of 74 patients (67.6%) Overall average 2.01 ± 2.6 discrepancies per patient Female: Male: 2.6 ± 2.9 discrepancies 1.6 ± 2.3 discrepancies

15 Types of Discrepancies (N=151) Wrong drug 8 (5%) Wrong frequency 14 (9%) Wrong dosage form 1 (1%) Wrong dosage 24 (16%) Unnecessary medication 60 (40%) Medication omission 44 (29%)

16 Discrepancies by Drug Class N/A Antiparasitic Agents Sensory Organs Genitourinary Agents Dermatological Agents Musculoskeletal System Antiinfectives Systemic Hormonal Preparations Respiratory System Nervous System Alimentary Tract & Metabolism Cardiovascular System Number of Discrepancies 39 43

17 Mean Number of Discrepancies By Reason for Admission Disease State # Patients (%) Mean Discrepancies ± SD Heart failure 36 (44.4%) 1.8 ± 2.4 COPD 26 (32.1%) 2.7 ± 3.1 Myocardial infarction 7 (8.6%) 1.3 ± 1.5 Acute renal failure 3 (3.7%) 1.3 ± 2.3 Hyperglycemia 2 (2.5%) 0.5 ± 0.7 End-stage renal disease 1 (1.2%) 4 Other 6 (7.4%) 1.5 ± 1.6

18 Mean Number of Discrepancies by Person Who Gathered Initial Medication History Title # of Patients (%) Mean Discrepancies ± SD Pharmacy technician 44 (59.5%) 1.9 ± 2.1 Other hospital staff 27 (36.5%) 2.3 ± 3.4 APPE student 1 (1.4%) 1 P6 student 1 (1.4%) 0 Unknown 1 (1.4%) 0

19 Medication Reconciliation Course Evolved to meet the needs of the college/students and the hospital site Fall 2017 Patients without completed home medication lists + targeted review for COPD patients Spring 2018 Changed from an Independent Study to an IPPE Elective and offered at several other local institutions

20 Key Points Medication reconciliation is a complex, multi-faceted tool with the ultimate goal of preventing patient harm Layered learning models beyond traditional IPPE/APPE experiences provide benefit to students, institutions, and patients

21 Questions

22 References Agency for Healthcare Research and Quality [Internet]. Rockville (MD): U.S. Department of Health and Human Services. Medication Reconciliation; [updated 2017 Jun; cited 2018 Mar 27]; [about 5 screens]. Available from: Gyllensten H, Hakkarainen KM, Hägg S, Carlsten A, Petzold M, Rehnberg C, Jönsson AK. Economic impact of adverse drug events: a retrospective population-based cohort study of 4970 adults. PLoS One Mar;9(3):e Hakkarainen KM, Hedna K, Petzold M, Hägg S. Percentage of patients with preventable adverse drug reactions and preventability of adverse drug reactions: a meta-analysis. PLoS One Mar;7(3):e Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med Care Dec;49(12): The Joint Commission [Internet]. The Joint Commission; c2018. National Patient Safety Goals effective January 2018; 2017 Nov 15 [cited 2018 Mar 27]; [17 p.]. Available from: Lancaster JW, Grgurich PE. Impact of students pharmacists on the medication reconciliation process in high-risk hospitalized general medicine patients. Am J Pharm Educ Mar 12;78(2):34. Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med Sep;23(9): Pinelli NR, Eckel SF, Vu MB, Weinberger M, Roth MT. The layered learning practice model: lessons learned from implementation. Am J Health-Syst Pharm. 2016; 73(24) Soric MM, Glowczewski JE, LermanRM. Economic and patient satisfaction outcomes of a layered learning model in a small community hospital. Am J Health-Syst Pharm 2016: 73 (7) Buckley MS, Harinstein LM, Clark CS, et al. Impact of a clinical pharmacy admission medication reconciliation program on medication errors in highrisk patients. Ann Pharmacother. 2013; 47(12):