Who s s on What? Latest Experience with the Framework Challenges and Successes November 29, 2005 Margaret Colquhoun Project Leader ISMP Canada 1
Outline ISMP Canada Partnership with SHN The Canadian Getting Started Kit Getting Started! Clarifications Moving ahead! 2 Institute for Safe Medication Practices Canada 2005
ISMP Canada Vision Realizing an international network that shares recommendations for the prevention of medication error- induced patient injuries. 3 Institute for Safe Medication Practices Canada 2005
Why Is Medication Reconciliation Important? The most frequently occurring type of medical error: Medication errors The most frequently cited category of root causes for serious adverse events: Ineffective communication The most vulnerable parts of a process: Links between the steps (the hand-offs ) Medication reconciliation addresses these 4 Institute for Safe Medication Practices Canada 2005
What is Medication Reconciliation? A process in which medications are compared at interfaces of care: Admission Transfer Discharge Discrepancies are identified and reconciled with physician Intervention minimizes patient harm from unintended discrepancies 5 Institute for Safe Medication Practices Canada 2005
Potential Impact of Medication Reconciliation as part of a series of interventions: decreased the rate of medication errors by 70%; reduced adverse drug events by over 15%. 1 scheduled surgical population: reduced potential adverse drug events by 80% within three months of implementation. 2 1 Whittington J, Cohen H. OSF Healthcare s s journey in patient safety. Qual Manag Health Care.. 2004;13(1):53-59. 59. 2 Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health-Sys Pharm. 2003;60:1982-1986. 1986. 6 Institute for Safe Medication Practices Canada 2005
Potential Impact of Medication Reconciliation Cont d: A successful medication reconciling process: reduces work and re-work reduced nursing time at admission by over 20 minutes per patient reduced pharmacists time at discharge by over 40 minutes. 3 3 Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care: impact of sliding scale insulin protocol and reconciliation of medications initiatives. J Qual Saf.. 2004;30(1):5-14. 14. 7 Institute for Safe Medication Practices Canada 2005
What we know from published studies Medication histories are often incorrect or incomplete 25% of Rx medications not listed 61% of patients have 1+ med not listed (Lau HS et al. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. Br J Clin Pharmacol 2000;49:597-603.) 8 Institute for Safe Medication Practices Canada 2005
What we know from published studies Many patients (37% on average) had drug omissions at admission (Cohen J, Wilson C, Ward F. Improve drug history taking. Pharmacy in Practice 1998;13-6.) 9 Institute for Safe Medication Practices Canada 2005
What we know from published studies Many patients (70%) not receiving medication instructions at discharge (Alibhai SMH, Han RK, Naglie G. Medication Education of Acutely Hospitalized Older Patients. J Gen Intern Med 1999 Oct;14: 610-616) 616) 10 Institute for Safe Medication Practices Canada 2005
The Goal of Medication Reconciliation To eliminate: Undocumented intentional discrepancies Unintentional discrepancies Potential Harm to patients 11 Institute for Safe Medication Practices Canada 2005
Conceptual Framework PMH primary medication history AMO admission medication orders BPMH best possible medication history Discrepancies Unintentional Undocumented intentional 12 Institute for Safe Medication Practices Canada 2005
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Intentional Discrepancy An intentional discrepancy is one in which the physician has made an intentional choice to add, change or discontinue a medication and their choice is clearly documented. This is considered to be best practice in medication reconciliation. 14 Institute for Safe Medication Practices Canada 2005
Undocumented Intentional Discrepancy An undocumented intentional discrepancy is one in which the physician has made an intentional choice to add, change or stop a medication but this choice is not clearly documented. 15 Institute for Safe Medication Practices Canada 2005
Example of an Undocumented Intentional Discrepancy Surgical admission on maintenance atenolol Surgeon- no admission order for atenolol - concerns re perioperative hypotension Reason not documented Patient discharged - discharge prescription did not include atenolol. Patient unsure whether to resume atenolol Called his family physician for advice. 16 Institute for Safe Medication Practices Canada 2005
An Unintentional Discrepancy An unintentional discrepancy is one in which the physician unintentionally changed, added or omitted a medication the patient was taking prior to admission. 17 Institute for Safe Medication Practices Canada 2005
Example of an Unintentional Discrepancies Patient on multiple medications admitted with stroke. Admission medication orders included propafenone,, (info in recent chart) Follow-up interview with patient's family and community pharmacy indicated medication had been discontinued one month prior to admission. Propafenone was stopped. 18 Institute for Safe Medication Practices Canada 2005
How we Implement Med. Rec 1. Secure Leadership Commitment 2. Form team 3. Collect Baseline Data 4. Set Aims (Goals and Objectives) 5. Start with a Pilot Project & Begin to Reconcile Medications 6. Continue to Implement, Test Results and Spread 7. Evaluate 19 Institute for Safe Medication Practices Canada 2005
3. Collect Baseline Data Review medication histories and admission medication orders on 10-20 current cases over one week: Follow normal process of taking a medication history - primary medication history (PMH)( Get best possible medication history (BPMH) 20 Institute for Safe Medication Practices Canada 2005
Collect Baseline Data Cont d: Compare admission medication orders (AMO) to best possible medication history (BPMH) to identify any discrepancies Clarify discrepancies with physician Identify: Unintentional Discrepancies (potential for patient harm) Undocumented Intentional Discrepancies (documentation issues) 21 Institute for Safe Medication Practices Canada 2005
Types of Discrepancies Type 0 no discrepancy Type 1 intentional discrepancy Type 2 undocumented intentional discrepancy Type 3 unintentional discrepancy 22 Institute for Safe Medication Practices Canada 2005
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Medications to Include Prescription medications What About? o OTC s o Herbals 24 Institute for Safe Medication Practices Canada 2005
FAQ: Are over the counter meds, and herbal meds to be included when doing the BPMH? The project is about improvement over time in your own facilities and we are comfortable with organizations choosing their own specific additions, if any, to RX medications. 25 Institute for Safe Medication Practices Canada 2005
Don t t be paralyzed in trying to get the perfect medication list! 26 Institute for Safe Medication Practices Canada 2005
Model for Improvement: PDSA What are we trying to accomplish? How will we know a change is an improvement? What change can we make that will result in improvement? Aim Measures Change Act Study Plan Do CYCLES for Testing and Implementing Change Langley, Nolan, Nolan, Norman, Provost; Improvement Guide, 1996 27 Institute for Safe Medication Practices Canada 2005
Virtually all hospitals who have successfully addressed admission reconciliation have created a special form as part of the solution. These forms pretty much look alike.
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What is included? Current home meds including dose, route & frequency The medications ordered at admission Continue, stop, start? Time of last dose Source of the information? Assessment of patient compliance? OTC s s and herbals (organization decsion) 30 Institute for Safe Medication Practices Canada 2005
Who uses the form? Nursing/pharmacist to collect information at admission. Physician - as reference and/or order when writing initial orders for medications. Physicians/nurses/pharmacists - throughout the patient s s stay as a reference. 31 Institute for Safe Medication Practices Canada 2005
FORMS
Criteria for Patient Selection (Taz Vira) Patient selection within units Significant indicators for patients requiring monitoring: 5+ medications 12 or more doses/ day Frequent hospital admissions (i.e. medication changes) 3+ comorbidities Presence of high risk drugs Other (Hx( of noncompliance, etc) (Koecheleler JA et al. Indicators for selection of ambulatory aptients who warrant pharmacist monitoring. AJHP Apr 1989;46:729-732) 732) 33 Institute for Safe Medication Practices Canada 2005
Evaluate Errors unintentional discrepancies Documentation Accuracy undocumented intentional discrepancies Success Index Run Charts Documented Intentional should become THE NORM 34 Institute for Safe Medication Practices Canada 2005
Mean number of undocumented intentional discrepancies 35 Institute for Safe Medication Practices Canada 2005
Mean number of unintentional discrepancies 36 Institute for Safe Medication Practices Canada 2005
Medication Reconciliation Success Index 37 Institute for Safe Medication Practices Canada 2005
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FAQ: Is a verbal order considered an intentional discrepancy or an undocumented intentional discrepancy? Usually if a pharmacist or nurse takes a verbal order they document the reason or the reason is apparent - intentional 39 Institute for Safe Medication Practices Canada 2005
FAQ: "If the physician writes new orders on admission due to a diagnosis but fails to document (as it is obvious to the physician) is this an intentional discrepancy or an undocumented intentional discrepancy? Definition- a formal process of obtaining a complete and accurate list of each patient s s current home medications and comparing to physician s admission orders. These are new orders and not included as discrepancies 40 Institute for Safe Medication Practices Canada 2005
FAQ For reconciliation at transfer point, do we reconcile against pt's HOME meds or just against institution's meds? If the patient s s medications have been reconciled at admission the reconciliation from that point on is to institutional orders 41 Institute for Safe Medication Practices Canada 2005
To be successful Start small begin with one nurse, one patient, one ordering physician Start smart where you are needed, where you ll get support Get baseline data and share broadly Involve administration if resources are an issue 42 Institute for Safe Medication Practices Canada 2005
To be successful Embed the medication reconciliation process into normal processes of care Engage staff by broadcasting the rationale and process Provide documentation tools 43 Institute for Safe Medication Practices Canada 2005
To be successful Involve patients Provide tools e.g. scripts for medication histories Look at what has been done in U.S. Work towards IT solutions 44 Institute for Safe Medication Practices Canada 2005
MEDICATION HISTORY SCRIPTING & TIPS FOR COLLECTING GUIDELINES Medication Allergies What medications are you allergic to? What did you experience last time it was given to you? How long ago did this reaction occur? Have you received and tolerated the medication since then? What other medications would you rather not receive because of a bad drug reaction (other than allergy)? Current Prescription Medications What prescription medications do you currently take? Why (or for what reason)? Are there any that you take only sometimes or when you need it? What and how often? Current Nonprescription Medications/Supplements What over-the-counter or nonprescription medications/supplements do you take? Why (or for what reason)? Are there any that you take only sometimes or when you need it? What and how often? Compliance/Education Opportunity How do you take your medicines (with food, morning, night, etc.)? What barriers prevent you from taking your medications as prescribed? (time, money, etc.) What medications have you recently stopped on your own? When and why? Who assists you with your medications? Have you taken anyone else s medications recently? Do you bring your medications with you to your doctor s office or carry a wallet med card? Physician/Pharmacy What pharmacy/pharmacies do you currently use? Do you see more than one physician (cardiologist, endocrinologist, oncologist, family physician, etc.)? Things to remember when interviewing: Utilize open-ended questions (what, how, why, when) and balance with yes/no questions Use nonbiased questions that do not lead the patient into answering something that may not be true Pursue unclear questions until they are clarified Ask simple questions, avoid using medical jargon, and always invite the patient to ask questions Let pt know the importance of using one central pharmacy/pharmacist Educate the pt on the importance of using a med wallet card and bringing their meds to the hospital, physician s office, etc. When asking about all medications, be sure to get name, dosage form, dosage, dosing schedule, last dose taken be as specific as possible about prn medications Prompt the patient to try and remember patches, creams, eye drops, inhalers, sample meds, shots, otc, herbals, vitamins, minerals When discussing allergies, educate pt on the difference between a side effect and a true allergy - rash, breathing problems, hives Have pt describe how and when they take their medications (more vague responses may indicate noncompliance) Steps to take if patient cannot remember a medication or if clarification is needed: Obtain a detailed description of the medication from pt or family member - dosage form, strength, size, shape, color, markings, Talk to any family members that are there or contact someone that could possibly bring in the medication or read it over the phone Try calling the patient s pharmacy to obtain a list of medications that patient has been regularly filling Contact the patient s physician/physicians to try and get an accurate listing of their current medications Obtain previous medical records 45 Institute for Safe Medication Practices Canada 2005
Together we will reduce potential adverse outcomes of care related to medications 46 Institute for Safe Medication Practices Canada 2005