Organization: Solution Title: Calvert Memorial Hospital Identifying Errors: A Case for Medication Reconciliation Technicians Program/Project Description and Goals: What was the problem to be solved? To improve the safety of using medications, The National Patient Safety Goal #3 requires that organizations "maintain and communicate accurate medication information" and "compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies." With a genuine desire to improve patient safety and satisfaction, and realizing that medication errors are the most costly medical related errors within the US health system, Calvert Memorial Hospital s Quality Management and Pharmacy Departments took a close look at the processes the hospital was using to reconcile medications used by patients and to communicate accurate medication information between levels of care. Several challenges were identified in efficiently and effectively reconciling patient medications: 1) Time spent with patients on medication reconciliation was taking nurses away from clinical care and increasing wait times in the ED. 2) Admission time for physicians was increased due to inaccurate and out-of-date medication lists. 3) Written information from patients and lists from Allscripts were getting lost in transition to the unit where patients were being admitted. After researching programs operated at many hospitals, the decision was made to request approval from the Board of Directors to hire a Medication Reconciliation Technician for peak days/times of patient utilization of the hospital. This created another challenge adding a staff member could help the organization better handle medication reconciliation; however adding staff is difficult when operating in a fiscally conservative nonprofit environment. Compounding the staffing challenging, CMH knew that cases existed which both support and rebut the utilization of a dedicated staff member for reconciliation. It was critical to articulate to the Board that the Medication Reconciliation Technician would be a valuable member of a comprehensive team dedicated to reducing medication errors while increasing efficiency of the reconciliation process the Technician would not be the champion for the effort but, rather, would help a team of champions enact the process better and contribute to overall gains in patient safety and satisfaction. How was it identified? In identifying the challenges CMH was experiencing related to medication reconciliation, three specific areas were looked at:
1) Staff factors - Prior to hiring an ED Medication Reconciliation Technician, medication reconciliation was complete by nurses in the ED, admissions nurses, and nurses on the floor when being admitted. The process was completed electronically in two different systems- Allscripts in the ED and Meditech for inpatients. Medication reconciliation, per our policy, is the responsibility of everyone involved throughout the continuum of care (nurse, pharmacist, and physician), however, with all the responsibilities that the admission nurse or ED nurse had for patients, medication reconciliation was often overlooked or completed incorrectly. This created not only a safety hazard to patients but was also a dissatisfaction to physicians due to not having the medication list before admitting the patient. 2) Patient factors - Compounding the challenges with medication reconciliation, patients often come to the hospital with incomplete lists of medications, and often do not know the names and/or dosages of their medications. Sometimes patients know the pharmacy where prescriptions are filled which provides staff with an opportunity to gather correct information on patient medication. 3) Peak times trends were discovered in the times when ED utilization was at higher volumes and the team could most benefit from assistance with medication reconciliation. What baseline data existed? To establish a case for support of the program, as well as a baseline to identify the success of any potential solution, a pilot was completed by Quality Improvement in response to multiple complaints by physicians that medication reconciliation was not completed appropriately upon admission. A quality nurse reviewed 20 patients - 10 from Level 2 and 10 from Level 3, each on the day after their admission. Their review identified if each patient s record was updated, complete, noted the last dose taken for each medication as well as the dosage and strength of each medication. There were several discrepancies and also interventions left in the chart for the physician to clarify. Of the 20 patients in the pilot, a 35% success rate was discovered in their medication reconciliation. What were the goals of the program/project, and how would you know if you were successful? The goal of the project was ultimately to reduce the risk of an adverse medication event by conducting an assessment of patient and resident medication regimen during an episode of care of Calvert Memorial Hospital. Through utilization of a team approach where all members were accountable to and supportive of others in championing improvements to medication reconciliation, clear guidelines and systems were created through the Department of Pharmacy Services. The team shared a clear vision that medication reconciliation is everyone s responsibility. Each member knew their responsibilities as well as the responsibilities of others. The Medication Reconciliation Technician would not solely handle all reconciliations but would provide assistance at peak times on busiest days allowing the nurses and providers to focus on clinical care.
Success of the program would be evaluated by based on overall medication reconciliation and patient satisfaction goals of the hospital indicated by: 1) Increases the accuracy of patient-provided medication lists 2) Increases in patient satisfaction in the Emergency Department 3) Increased savings to the organization through event avoidance 4) Reductions in readmissions due to medication errors 5) Decreasing the amount of time physicians and nurses spent with each patient on medication reconciliation during peak times. Process(es) implemented: What methodology or process was used to develop the solution? During a FMEA, conducted in 2013 on our medication reconciliation process, we realized that the process was fragmented in several places. However, two factors significantly impacted the process and created barriers: 1) Having multiple electronic health records systems, 2) Having staff that is not trained on all systems. The Medication Reconciliation Committee meets monthly to review procedures, polices, and also workflows to help improve our current process. After re-educating staff and redesigning the system to reconcile medications, the process was still not yielding the improvements anticipated. CMH engaged OPSIC (Organizational Performance Improvement and Safety Committee). Based on the recommendation of OPSIC, the leadership of CMH chose to budget for the inclusion of dedicated Medication Reconciliation Technicians during peak times of utilization of the hospital s ED. Solution identified: What solution was developed? How was it implemented? CMH physicians became champions of the effort the hire 2 Medication Reconciliation Technician (MRT) to serve during peak hours. Our lead hospitalist presented a proposal to the CMH Board of Directors which demonstrated how dedicated MRTs in the ED would improve overall patient safety and workflow. The Board granted the request through their endorsement of the positions and granted a 3-year budget allocation in FY2015. Once the position description was completed, the positions were advertised - 20 applicants expressed interest. Under supervision of the CMH Director of Pharmacy, two candidates were hired. Coverage for medication reconciliation was provided during the following peak times: Sunday Monday Tuesday Wednesday Thursday Friday Saturday 11am 9pm 11am 9pm 12pm 8pm
The newly hired technicians have adopted workflow from the nurses. The technicians interview all new admissions and enter each patient-provided list of home medications into the Allscripts and Meditech systems. The technicians also work with patient pharmacies to fill gaps in the lists provided by patients. By utilizing the technicians, nurses are able to return to the clinical care of patients which has resulted in reduced turn-around time in the ED. Additionally, the time between admission and the patient receiving care from the physician has been decreased because medication lists are accurate and up to date. Measurable Outcomes: What are the results of implementing the Solution? Provide qualitative and/or quantitative results to data. (Please include graphs, charts, or tools). Once the technicians were hired, trained and began serving in the ED in October 2014, CMH quickly realized that the medication lists generated for each patient, as compiled by the MRT, were significantly more accurate and resulted in a reduced number of potentially harmful errors. The following chart demonstrates the impact of the technicians through their identification of medication discrepancies: Month # of patients served by technician # of patients with medication discrepancies (identified by technician) Oct 2014 385 296 Nov 2014 495 411 Dec 2014 573 452 Jan 2015 537 424 Feb 2015 425 317 Mar 2015 496 313 Apr 2015 224 191 May 2015 229 223 Jun 2015 357 312 Jul 2015 394 362 Aug 2015 328 306 Sep 2015 311 293 Oct 2015 325 310 The technicians at CMH see an average of 18 patients per day, and spend an average of 25 minutes with each patient. Additionally, CMH has experienced a significant decrease in transcription errors from 20 in 2013, 11 in 2014 and 4 to date in 2015. Overall medication events have decreased from 385 in 2013 to 169 in 2014 and 125 to date in 2015 representing a 67% reduction in medication error events.
Sustainability: What measures are being taken to ensure that results can be sustained and spread? Demonstrating positive outcomes, including fewer medication errors, increased physician satisfaction, increased time for nurses to provide direct patient care and increased patient satisfaction, has reassured the CMH Board of the merit of this investment. The Board has confirmed its commitment to patient safety related to medication error avoidance through their agreement to include staffing for two Medication Reconciliation Technicians as a permanent part of the CMH annual operating budget. Role of Collaboration and Leadership: What role did teamwork and collaboration play in the Solution? What partners and participants were involved? Was the organization s leadership engaged and did they share the vision for success? How was leadership support demonstrated? The collaboration between the leadership of Quality Management, Pharmacy and CMH physicians drove the process of developing the case for adding Medication Reconciliation Technicians to the ED team. CMH physicians became champions of the solution and advocated for the solution to the hospital s Board leadership. Ultimately, the CMH Board of Directors expressed their belief in the value of these positions and their potential for increasing patient safety through their approval to fund the new positions. Innovative attributes: What makes this solution innovative? What are its unique attributes? CMH approached the addition of the Medication Reconciliation Technicians as members of a team versus simply staff to recover workload from others. Because the technicians are not currently 24/7 positions at CMH, nurses and physicians still play a critical role in the overall effort to improve medication safety. The technicians have become the champions for medication reconciliation and serve as valuable assets and resources to the hospital team. The technicians not only work with patients to develop accurate lists of medications, but they have been proactive in training staff on the two electronic health record systems (which presented significant challenges as identified in the initial phase of the program) and ultimately leading to success in the hospital s efforts to decrease adverse effects related to the accuracy of patient medications. Related Tools and Resources: Contact Person: Kara Harrer Title: Director of Pharmacy Email: kharrer@cmhlink.org Phone: 410-414-4768