Medication Reconciliation Where are we now? Angie Powell, PharmD Director of Pharmacy Baxter Regional Medical Center
Disclosures I, Angie Powell, have no relevant financial relationships to disclose.
Learning Objectives Describe pharmacy department involvement in medication reconciliation List the possible barriers and limitations related to designing and implementing a successful medication reconciliation program Discuss the successes and outcomes of an implemented medication reconciliation program
Polling Question #1 Which of the following best describes you? A. Pharmacy Technician B. Pharmacist
Polling Question #2 Is pharmacy staff involved in collecting medication histories at your institution? A. Yes B. Not yet, but working to implement C. No
Baxter Regional Medical Center 268 bed acute care facility Average census 110-120 Pharmacy services provided 24 hours per day 14 Rx Tech FTEs 11.5 Pharmacist FTEs Occasional APPE student
BRMC Pharmacy Services Renal dosing Vancomycin and aminoglycoside dosing Antimicrobial surveillance Anticoagulation monitoring TPN management IV to PO conversions Dedicated ICU Clinical Pharmacist Admission medication histories
Medication Reconciliation: Beginning, Middle, and End Admission Gather up the best list possible Ensure that what needs to get ordered, does Transfer Change in level of care, time to make sure patient is on the right meds again Discharge Ensure that the patient goes home on the right meds, and that they get a good list
Polling Question #3 Inaccurate medication histories are a source of frustration for me in my practice. A. True B. False C. Not Applicable
Admission
The BRMC Med History Experience April 2007 - Electronic Nursing Documentation, including Meds by Hx December 2010 CPOE Pilot Significant physician frustration around electronic med rec October 2011 Pharmacy Med History Team launches focus on patients likely to be admitted from ED and direct admits October 2012 Added Presurgical Testing Spring 2014 Added Behavioral Health
Recognizing the need Quality of Med Hx performed by nursing was known to be an issue before CPOE go-live Multiple attempts were made to improve nursing skills around this activity minimal impact During CPOE go-live, physicians became extremely frustrated with the number of hard stops encountered when completing admission orders
Polling Question #5 What percentage of medication histories at your institution are accurate? A.90ish% B.75ish% C.50ish% D.<50% E.We ve never checked
Quantifying the Problem Random audit of 136 documented home medications 50% had missing details (dose, route, and/or frequency) 2 patients had ZERO medications documented correctly Every patient had at least one error noted Four patients had completed ED prescriptions from previous visits left as active on their list
The BRMC Pharmacy Med Hx Team
Our Solution Pharmacy Medication History Team Staffed 07:00 17:30 Seven days per week Team comprised of pharmacists and technicians Mon Thu: 1 pharmacist + 1 tech Fri: 2 techs, supervised by point of care pharmacist Sat Sun: 1 tech, supervised by point of care pharmacist
Pharmacy Tech Role Interview patients Follow-up detective work Transcribing into EHR Typically complete 18 20 med history interviews per day
Pharmacist Role Clinical pharmacy resource in the ED Interview patients Follow-up detective work Transcribing into EHR Verifying technician s work Contacting prescribers when new information suggests changes need to be made to inpatient orders
Team Statistics - 2014 >13,000 med history interviews performed >7,000 allergies clarified 11 percent of preventable medication errors result from drug allergies or harmful drug interactions. >3,500 home med history errors fixed Based on Thomson Healthcare Action O-I estimates, each prevented med error avoids $220 - $2,200, depending on severity. Using that estimate, our Rx Med History team avoided somewhere between $770,000 and $7.7 million in 2013.
Physician & Nursing Satisfaction Physician satisfaction with electronic med reconciliation has significantly improved, with many physicians refusing to reorder home meds if the history was not collected by our team Nursing has been able to repurpose an estimated 2,500 hours per year
Collateral Benefits Improved collaboration with nursing Improved collaboration with physicians Improved pharmacy presence in the ED and perioperative areas, with impact beyond admission meds
Barriers and Obstacles Patient Poor health literacy Don t always consider OTCs, herbals, eye drops, insulin to be medications Assumptions that their physician has an accurate list already Frustration when somebody else already asked them about meds
Barriers and Obstacles Nursing Integrating your services into a busy ED team Coordinating your interview with nursing during the hectic admission process Earning trust Breaking old habits
Barriers and Obstacles Coverage Patients get admitted during off-service hours Efforts to improve nursing med history skills continue to bear little fruit Budget request for additional tech FTEs to expand service hours in progress for 2016
Discharge
The BRMC Discharge Med Rec Experience Before CPOE: Physician writes discharge med orders on paper Pharmacist reviewed for omissions, duplications, dosing errors Pharmacist transcribed into EHR to generate patient med list After CPOE: Physician enters discharge med orders into EHR Not routed to pharmacist for review Mistakes not caught
Our Solution EHR Alert to Pharmacist Physician completes discharge med orders Rule fires alert to pharmacists unverified order monitor Pharmacist opens patient s chart to review orders, contacts physician for clarifications if needed
Examples of error prevented Physician didn t continue anti-platelet therapy for a patient immediately post-stent placement Physician ordered both pre-admission and new dose of insulin to be given upon return home Physician didn t continue anticoagulant for patient going home after knee replacement surgery
Barriers and Obstacles Not having complete knowledge of the patient Pressure to get patient out the door Getting physicians to call back in a timely manner
Additional Resources Cooper JB, Lilliston M, Brooks D, Swords B. Experience with a pharmacy technician medication history program. Am J Health-Syst Pharm. 2014; 71:1567-74 Gleason KM, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health-Syst Pharm. 2004; 61:1689-95