Mental Health Pharmacist Education Medication Reconciliation Patient Safety Initiative August 2015
Introductions
Agenda MedRec Project Overview Project Structure Implementation/Dates MedRec Basics What is MedRec? Why do we need MedRec? MedRec Information Admission & Responsibilities Transfer & Responsibilities Discharge & Responsibilities MedRec Resources
MedRec Project Team Medication Management Advisors: Gordon Stewart, Corporate Director, Integrated Clinical Services Jan Schimpf, Senior Operating Officer, Acute Services, MCH Executive Project Sponsor: Jon Popowich, Chief Quality & Privacy Officer Project Lead: Theresa Imlah, Manager, Medication Management Administrative Project Support: Ebelina Topping, Program Assistant, Medication Management Program Project Coordinator: Meilai Ha, Medication Management Pharmacy Technician: Jessica Currie, MedRec Medical Physician: Dr. Sarah Burton MacLeod, MedRec Pharmacist: TBD, MedRec (0.5 FTE) (1.0 FTE) (0.2 FTE) (1.0 FTE)
Mental Health Implementation Dates: Misericordia: August 31, 2015 Villa Caritas: September 21, 2015 Grey Nuns: October 5, 2015
Local Implementation Implementation: Week One: Project Team is physically present on the local unit/site for first week Support Champions Coaching & guidance for local staff on the use of MedRec tools/processes Week Two: Project Team available remotely via pagers At the end of the month: auditing commences (See dates on next slide)
Important Dates: MCH Education Aug 24 28, 2015 Implementation Dates Aug 31 Sept 11, 2015
MedRec is under the Umbrella of Medication Management Standardized Medication Concentrations Medication Reconciliation Narcotics Safety High Alert Medication Safety Strategies Medication Management Heparin Safety Concentrated Electrolytes Safety Antimicrobial Stewardship Others?
We have all seen it happen: At the monthly management meeting of a large urban hospital, the head of patient safety announces: We had a critical incident last week. A patient was readmitted two days after discharge with severe hypoglycemia. The treating team discharged the patient on a new insulin regimen without realizing that the patient also had insulin 30/70 at home. The patient continued to take her previous regimen as well as the new one, and was found unresponsive by her husband. She s in the ICU and probably will have permanent neurological deficits. After various sighs and exclamations from around the table, the chief medical officer asks, incredulously, Why didn t this get picked up? Before anyone can answer, the executive adds: We had that other case six months ago in which a patient was discharged without restarting his warfarin, and he ended up having a stroke. Adapted from: Fernandez O, Shojania K. (2012). Medication Reconciliation in the Hospital. What, why, where, when, who and how? Healthcare Quarterly Vol. 15 Special Issue 2012.
What is Medication Reconciliation? Patient Safety Initiative Goal: Develop a structured process to ensure that comprehensive and accurate medication information is collected and follows the patient s journey during key transitions of care (admission, transfer and discharge). Accreditation Canada ROP Requirement
Why do we need MedRec? Patient Safety Awareness Communication and Collaboration Minimize adverse drug events and medication errors at key transitions of care Increase knowledge and awareness of the importance MedRec Enhance transparency of information between healthcare providers and the patients across key transitions of care
Key Transitions of Care Step1 Complete a Best Possible Medication History (BPMH) Step 2 Reconciliation on Admission Step 3 Reconciliation on Internal Transfer (change of service within facility/hospital) Step 4 Reconciliation on Discharge (case number closed; discharged to home/another healthcare facility)
Admission
Admission Best Possible Medication History (BPMH) is the cornerstone of the MedRec admission process. BPMH is: a medication history a reference point for decisions to continue, discontinue or modify the medication regimen during key transitions of care acts as the one source of truth serves as medication orders on admission (once reconciled and signed by prescriber)
Admission Identify, document and resolve discrepancies Decision to admit patient Document all home medications on Admission BPMH Tool Reconcile Medication on admission BPMH are transcribed/ processed Prescriber reviews, completes and signs Admission BPMH Tool
BPMH Date/Time the history completed All prescribed home Medications [including Over-the-counter (OTC) medications if they were PRESCRIBED to pt.] Self-prescribed Medications (for information purposes only) Sources used to obtain History. Minimum TWO sources should be used. Reconciliation section (Prescriber Use Only) Prescriber signs & includes date and time of reconciliation Additional Comments (information purposes only) Page #s
Who will be completing the BPMH? The Admitting Prescriber (Psychiatrist/Resident) or student will initiate the BPMH (left side) The Admitting Prescriber will then reconcile and sign the Prescriber Reconciliation section (right side) to generate admission orders for processing The Unit Clerk/Charge Nurse will then process the admission orders
Direct Admit to Unit Patients who already have a completed admission BPMH from another site (copy faxed to your site). In this case: The BPMH will not serve as inpatient orders, but as a history/reference only. A new BPMH is not to be completed. The MedRec for DIRECT ADMISSIONS sticker will be used. (see next slide)
Direct Admit to Unit If a patient is directly admitted to the Unit from another facility and already has a BPMH completed, the Admitting Prescriber (Psychiatrist/Resident) will generate admission orders and utilize the MedRec for DIRECT ADMISSION sticker to acknowledge they have: Reviewed the BPMH and Transfer orders from the sending facility to generate the admission orders MedRec for DIRECT ADMISSIONS Admitting Prescriber to complete: I have reviewed the patient s Best Possible Medication History (BPMH) and the medication transfer orders from the sending facility to generate these admission orders and have documented any medication discrepancies. Signature: Date/Time: The Unit Clerk/Charge Nurse will then process the admission orders
Who will be completing BPMHs? Mental Health: Admission Process (MCH) (see previous slide) to
Who will be completing BPMHs? Mental Health: Admission Process (VC) previous slide) to acknowledge the
Admission A BPMH may be completed prior to, or alongside, all other admission orders being written (Proactive/Prospective Model) After initial admission orders have been written (Retroactive/Retrospective Model). or In either case, a BPMH should ideally be completed within 24h of admission. 8.6 25
Divisions of Authority to Complete LEFT SIDE: Medication History (may be completed by a licensed Health Care Professional; this includes, but is not limited to, prescribers) RIGHT SIDE: Prescriber Use Only Section of BPMH
How to Complete the BPMH Tool Pharmacists will not be completing BPMHs See How to Fill Out a BPMH Tool on CompassionNet
BPMH Tips: Validate the history using at least TWO (2) sources of information. One of the sources should ideally be the patient and/or family member. Even if a medication is an over-the-counter (OTC) product, it is still written in the top/main section IF it has been PRESCRIBED for the patient If it was not prescribed to the patient, it should be documented in the Comments Section
Late Entries/Addendums New information may be learned about the patient s HOME medications after the BPMH is processed. Because this history is referred to at all key transition points, it should be as accurate as possible. Any licensed health care professional may document an addendum. Write Late Entry along with the name, dose, frequency and route of the medication Date, time and sign your entry If there is no room, start a new page and renumber all associated pages
Late Entries/ Addendums Notify the prescriber to address the discrepancy Do NOT process/scan to pharmacy again Any orders needed are to be written on the Patient Care Order (Pink) sheets C SCANNED
Where will the BPMH be kept? The BPMH will be kept in the Patient Care Orders Section (pink sheets) of the chart in chronological sequence.
What are my responsibilities? Providing support and clinical expertise to the Prescribers when needed as they complete BPMHs. Document and address late entries, if discovered.
Acute Hospital Transfer Villa Caritas Bed Held
Acute Hospital Transfer - Villa Caritas Bed Held When a patient is to be transferred to another Acute Hospital and the Villa Caritas bed is held For Example: Patient is scheduled for an elective surgery or test The patient suddenly requires medical treatment/observation at an Emergency Department
Is there a tool for Acute Hospital transfer? The MedRec Acute Hospital Transfer sticker will be placed onto the most current Medication Profile or MAR that is to be sent with the patient The Sending Prescriber (Psychiatrist /Resident) will sign and date/time the MedRec Acute Hospital Transfer sticker Both the Medication Profile/MAR and a copy of the BPMH is to be sent to the receiving facility
Exception: In extenuating circumstances, where the Sending Prescriber is not available (i.e. late at night) and the patient is promptly required to be transferred to another acute hospital, the Acute Hospital Transfer sticker is not required to be signed. Please note that in this situation, both the most current Medication Profile/MAR and a copy of the BPMH is still required to be sent to the receiving facility
When the patient comes back to Villa Caritas When the patient is transferred back to Villa Caritas and had been admitted to the Acute Hospital, the MedRec for DIRECT ADMISSION sticker (see below) is required to be signed by the Prescriber to ensure the BPMH & most current transfer orders have been reviewed. If the patient was not admitted to the Acute Hospital, no action is required. MedRec for DIRECT ADMISSIONS Admitting Prescriber to complete: I have reviewed the patient s Best Possible Medication History (BPMH) and the medication transfer orders from the sending facility to generate these admission orders and have documented any medication discrepancies. Signature: Date/Time:
What are my responsibilities? No official responsibility at transfer Important to be aware of the process and during the change help to remind prescribers this needs to be done
Discharge
Discharge Refers to the end of service provision by the care facility (i.e. the patient physically exits the current facility and subsequently goes home or to a different care facility) Tip: Elvis has left the building and is not returning (Case number is closed)
Discharge (Or Medication Profile)
Why a Discharge MedRec Tool? Complete and accurate list of discharge medications Plus a list of discontinued home medications Once signed by prescriber: Discharge medication orders (if going to another facility) and/or Prescription (if a quantity specified) Replaces current discharge prescription process
Discharge MedRec Tool Date and Time Prescribers Orders Bubble Packaging Requested Community Pharmacy Information Other Important Information Discharge Medication List Prescription/Quantity Discontinued Medications (Prescribed and Self-prescribed) Prescriber Name and Signature Unit Contact Information Page #s
Discharge Tool: Two-ply White (top) ply: Chart copy. If patient would prefer to take this copy in person to his or her pharmacy, a photocopy of it must be made for the chart. Yellow (bottom) ply: Copy for patient/resident or caregiver for information purposes Patient/caregiver will always receive this copy.
If Discharge Tool is faxed to a Community Pharmacy In this case, the patient will ONLY receive the Yellow (bottom) copy
Who will complete the Discharge MedRec Tool? The Pharmacist (M-F 0800h- 1530h) will initiate the Discharge MedRec Tool when a minimum of 24 hours advance notice is provided If the Pharmacist is not available, the Discharging Prescriber (Psychiatrist/Resident) is to complete the Discharge MedRec Tool The Discharging Prescriber(Psychiatrist/Resident) will perform the final review and will sign the MedRec Discharge tool making it an order/prescription The Unit Clerk/Charge Nurse will process the discharge orders and the Pharmacist and Nurse will work together to provide education to patients
How to complete the Discharge Tool At the top of the discharge tool, a space is provided for the: Date and time Community Pharmacy information (if applicable) In the Check all that apply section, a check mark will indicate any statements the prescriber would like to use as orders i.e. If, Send to Primary Care Physician is checked off the Unit Clerk/Charge Nurse will fax the completed Discharge tool to the Primary Care Physician and initial beside the task to indicate it has been completed.
How to complete the Discharge Tool All medications the patient is to take after being discharged from the site will be listed. Beside each medication, a check mark will indicate whether the medication is: Continue Unchanged PRE-ADMISSION medication Changed PRE-ADMISSION medication has been changed during hospitalization (dose, route, or frequency). Include rationale in space provided. New New medication started while in hospital. Include rationale in space provided.
How to complete the Discharge Tool When a prescription is required, the prescriber will indicate the quantity in the designated column If no qty is required, strike a line through the column If a refill is desired, the prescriber will indicate in the designated column If no refills are required, a line will be struck through the column
How to complete the Discharge Tool Triplicate (TPP) medications should still be listed on the discharge tool to ensure the list is complete Additionally, a Triplicate Prescription is required (unless the patient is going directly to another inpatient facility) In the Discontinued HOME Medications section (see stop sign), any HOME medications that were discontinued during hospitalization and are NOT to be given on discharge will be listed FYI: Instructions are also on the back of the white copy (top copy) of the form
Do I still complete discharge MedRec if the patient does not have a BPMH? Effective the start date of implementation, the plan is for a discharge MedRec tool to be completed for all Mental Health patients being discharged.
Discharge directly to another facility Discharge MedRec tool serves as discharge medication orders for the next facility. BPMH should also be faxed to the receiving facility in addition to the discharge MedRec tool. This provides the receiving facility with an understanding of the patient s home medications, as a point of reference.
Discharge tips: Ensure all medications on the BPMH are accounted for upon discharge. The tool must be signed and dated by the prescriber. Once signed and dated by the prescriber, this tool becomes a discharge medication order and a legal prescription (if quantity column is completed).
What are my responsibilities? You will take lead role for discharge MedRec: Reconciling the medications that the patient was on at home with what they are to take on discharge. Assisting with filling out the Discharge Medication Reconciliation tool for patients being discharged during your clinical hours In conjunction with discussion with the prescriber, as needed, during this process. Provide/flag to prescriber for final review and signature.
What are my responsibilities? Educating the patient and their family/caregiver which home medications are to continue, which were changed, which were stopped and which medications were started while in hospital. Document that education was provided.
Measurement and Evaluation
Measurement and Evaluation: Auditing: Auditing of admission and discharge MedRec will occur on a monthly basis by your unit s designated auditor. Measure Success Measure Quality Measure Outcome Measure Question Was MedRec completed? Goal: above 90% Was it done well? Goal: above 80% Were there any discrepancies? Goal: under 10%
Admission Audit Tool:
Discharge Audit Tool
MedRec Resources CompassionNet Internal and External Resources MedRec Policy On Deck with MedRec Newsletters MedRec Info Binders Including flow sheets Binder will be at unit clerk s desk on 6 East and 6 West MedRec Project Team medication.management@covenanthealth.ca
MedRec Page: CompassionNet 1. Go to www.compassionnet.ca 2. Click Care & Safety 3. Then click on 4. Then click on
Other Useful Links Accreditation Canada http://www.accreditation.ca/ Canadian Patient Safety Institute (CPSI) http://www.patientsafetyinstitute.ca/ Health Quality Council of Alberta (HQCA) http://www.hqca.ca/ Institute for Safe Medication Practices Canada (ISMP) http://www.ismp-canada.org/medrec/ Safer Healthcare Now! http://www.saferhealthcarenow.ca/en/pages/default.aspx Alberta Health Services (MedRec) http://www.albertahealthservices.ca/9322.asp
If I have questions, who do I ask? MedRec Champions MedRec Team During implementation dates: in-person and via pagers; Pager #1: (780) 445-5398 (Jessica) Pager #2: (780) 969-9879 (Meilai) After implementation dates: via email Medication.management@covenanthealth.ca
RLS If you discover any MedRec related incidents, please report them as you would any other incident discovered.
Contact Us Do you have proposed changes to the MedRec initiative? Complete a Change Request Form (available on CompassionNet) Submit to: Meilai.Ha@covenanthealth.ca Questions? Feedback? Email medication.management@covenanthealth.ca