Medication Reconciliation


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Learn best practices based on literature and how to perform a complex and accurate medication history. Recognize gaps/inconsistencies in systems that impede medication reconciliation and identify next steps in improving current medication reconciliation within your own practice.

Mary Pat Friedlander, MD
Lawrenceville Family Health Center
Pittsburgh, PA

Published in: Health & Medicine, Business
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  • 2009 –review of omitted and discharged medications in discharge summary
  • Bottom line—many organizations have recognized the importance of medication reconciliation as part of quality medical care to prevent errors
  • Minimal application/need for Med Reconciliation
  • Make them aware of the importance of accurate medication list
  • Who ordered , what is the dose—what dose it look like, where did you get it, when did you last take it, why are you on it
  • Anticoagulants, insulin, theophylline, narcotics
  • There are many of studies that show that this can workProject Red
  • Medication Reconciliation

    1. 1. Mary Pat Friedlander, MD UPMC St Margaret’s Residency Program October 23, 2013
    2. 2.  Neither I nor any immediate family member (parent, sibling, spouse or child) has a financial relationship with or interest in any commercial entity that may have a direct interest in the subject matter of this session.
    3. 3.    Define the components of an accurate medication reconciliation Recognize gaps and inconsistencies in the medication reconciliation process Identify next steps in your practice to improve medication reconciliation
    4. 4.   Poor communication at transition points led to 50% of the medication errors and 20% of adverse drug reactions Variability in medications patients take prior to admission and admit orders up to 70%
    5. 5.  Discharge drug summaries    66% one inconsistency 32% potentially harmful drug omissions 17% unjustified medications  16% were potentially harmful
    6. 6.  2005-National Patient Safety Goal #8    2009-Announcement of need for change   8A-process must exist for comparing current meds with those ordered while in the organization 8B-complete list of medications must be communicated to the next provider on service or outside the organization and a complete list given to patient at discharge. Many organizations came together 2013—NPSG #3.06.01
    7. 7.  Improve the safety of using medication    1. Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings 2. Reduce the likelihood of patient harm associated with the use of anticoagulant therapy 3. Maintain and communicate accurate patient medication information.
    8. 8.  Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their upto-date list of medicines every time they visit the doctor.
    9. 9.  100,000 lives campaign—2005 (18 month project)  Prevent ADE’simplementing med reconciliation
    10. 10. PCMH 3: Plan and Manage Care • Identify patients with specific conditions including high-risk or complex, behavioral health • Care management – Pre-visit planning – Progress toward goals – Barriers to treatment goals • Reconcile medications • E-prescribing Meaningful Use Criteria • Clinical decision support • Medication reconciliation with transitions of care • E-prescribing • Drug-drug, drug-allergy checks • Transmit prescriptions using EHR • Drug-formulary checks
    11. 11.  Medication reconciliation post-discharge: percentage of discharges from January 1 to December 1 of the measurement year for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge.
    12. 12.  Process of identifying the most accurate list of all medications a patient is taking    Name, dosage, frequency and route Use this list to provide correct medications for patients anywhere within the health care system Compare the patient’s current list against the admission, transfer or discharge orders
    13. 13.    Verification—collection of medication history Clarification—ensuring medications and the dosages are appropriate Reconciliation-Documenting the changes in the orders
    14. 14.     Drug is started Drug is discontinued Dose of drug changed Frequency of administration is changed
    15. 15.      Engage the patient Engage the caregivers Ask open ended questions Have patient bring in ―bag of meds‖ Provide a list of meds Date the list
    16. 16.   Use systematic approach Ask about allergies     Medication allergies Reactions Other allergies Prescriptions  Do you take anything prescribed every day  How many times a day   Do you take anything on as needed basis Do you take anything prescribed by other provider
    17. 17.  Prescriptions     Do you use any patches or creams Do you receive any injections at the doctor’s office Do you take any sample medications OTCs   Do you take any medications that don’t need a prescription What do you take when you get sick? Heartburn? Menstrual cramps? Headaches?, etc.
    18. 18.  Herbals/Natural/Vitamins      What vitamins do you take What herbal medications do you take What natural supplements do you take What dietary supplements do you take Review Medical Problems list  Do you take anything for your high blood pressure? diabetes? your heart? thyroid?, etc.
    19. 19.  Medication Concerns Tell me about missed doses in the last week  What problems do you have with your meds?  What concerns do you have about side effects  Tell me about any difficulty paying for your meds?  Tell me about any medications that you don’t think are helping you?   Medications with incomplete information  Who, what, where, when and why?
    20. 20.  Admission   Transfer   *Accurate* Medication History Compare home meds, current meds and transfer Discharge    Same as transfer Share list with provider and patient Teach patient/family  Discontinued  Resumed meds (i.e. metformin)  New Meds
    21. 21.    ER, tests, same day surgery, procedure Current Meds Let know of any changes or need to discontinue medication
    22. 22.   Collect Medication list/Verify a previous list Two Questions    Did any current medication change? Have any new prescriptions been added? Give clear instructions on the change   Have in writing Have patient teach back the new change
    23. 23.  Who owns the process?       No standardized process for home med list Doctors won’t order meds they did not give Time Just another form Patients without knowledge of meds   Doctor, nurse, MA, pharmacist Blue pill, heart pill, ―I don’t know, don’t you know‖ Link of Current Med list to Order screen
    24. 24.  Very little data to compare   Time/Labor intensive     Different processes/solutions Hiring discharge advocate/pharmacist Hard to study Different EMR systems Many studies outside of US
    25. 25.      Patient Centered Easy to complete for all Home list is available when prescribing meds Patient gets up-to-date list All providers are aware of changes
    26. 26.    Agree on definitions Get buy in from leadership No one size fits all approach    Limit number of processes Defects found are part of the larger system   Inpatient vs. surgery vs. ER vs. outpatient settings Not by-product of process Specify who is responsible  Hold them accountable
    27. 27.  Develop a process   May include forms Establish communication  Across spectrum of care  Nursing homes, Long term care facilities, clinician offices, specialists, home health agencies   Don’t do in committee—Engage stakeholders Use Model for Improvement Strategy  PDSA, etc.
    28. 28.      Process should identify failure of system and help correct the failure Train staff Develop guides for patients/staff Involve patients in design of medication list card—can there be universal card in your area? If form not used in intended way   Ask why? Does form need to be changed? Does their need to be more training
    29. 29.    Do a small pilot program Start in one clinical area Use specific high risk patients   Age >65 4+ chronic medications  High risk medications  3+ chronic medical conditions
    30. 30. Inpatient studies 1. 70% decrease in medication errors 15% decrease in adverse drug events 2. Decrease amount of time spent to rework 3 Discharge Advocate and pharmacy phone calls decreased 23.8% decrease in hospital utilization 30 days post discharge
    31. 31.   Little data on outpatient Clinical pharmacists with most data   Meet with patients in the office Reconcile meds  Saved money  Billing by pharmacist?
    32. 32.  Depart Process   Med Rec at admission, transfer, discharge ―Patient Friendly‖ Summary given  Email generated to PCP (if in system)  Residency Practice PharmD Resident calls patient at d/c Reviews meds/arranges f/u
    33. 33.    Dependent on Admission Rx to be accurate Dependent on the correct PCP in computer Dependent on patient understanding med list      Health literacy Large d/c packet—too much information Teach back Outpatient EMR and Inpatient EMR Dependent on f/u phone call  Numbers not accurate
    34. 34.  IHI    Project RED   How to Guide AHRQ   Free tool kit--MATCH
    35. 35.    Define the components of an accurate medication reconciliation Recognize gaps and inconsistencies in the medication reconciliation process Identify next steps in your practice to improve medication reconciliation
    36. 36. THANKS Amy Haugh, MLS Director, Medical Library Services UPMC St Margaret
    37. 37.    How-to-Guide: Prevent Adverse Drug Events by Implementing Medication Reconciliation. Cambridge, MA. Institute for Healthcare Improvement; 2011 ( 2013 Hospital National Patient Safety Goals ( Van Sluisveld et al. BMC Health Services Research 2012, 12:170
    38. 38.    Greenwald, et al. Medication Reconciliation: A Consensus Statement from the Stakeholders. Journal of Hospital Medicine 2010 5(8) 477-485 Smith, M, et al. In Connecticut: Improving Patient Medication Management in Primary Care. Health Affairs 2011 30(4) 646-654 Mueller, S, et al. Hospital Based Medication Reconciliation Practices: A Systematic Review Arch Intern Med. 2012;172(14):1057-1069.