2. Team Members
• Karyn Batdorf, HR, Team leader
• Lisa Blaase, Pharmacy
• Susan Hawes, Pharmacy
• Geoff Lockwood, Pharmacy
• Ryan ‘Wolverine’ Schell, Pharmacy
• Chris Senn, Pharmacy
• Jonna Whiteman, PCU
• Amanda Mack, TVM facilitator
3. Reason for Action
Preventable heart failure patient readmissions is costly to the
hospital. Medication therapy in HF patients play a huge role in
this problem. An inaccurate admission medication list leads to
inaccurate discharge medication lists. This process is essential
to patient safety, helps patient adherence and satisfaction, and
reduces potential errors.
4. Meds by History vs Med Rec
Meds by history:
the list of patients’ home
medications that is found
in Cerner. This is to be
completed within 24
hours of admit.
Medication
Reconciliation:
Pulls from the meds by
history list. This is the
actual physician order for
the which meds to
continue or discontinue.
5. Initial State
• Patients do not present with up-to date med lists
• Meds by history is rushed through – just trying to check it off the list
• No method to identify HF patients in ED or as inpatient
• There are multiple people in the med history process – nurse(s) in ED,
pharmacist in ED, floor nurse(s), floor pharmacist
• Hard to get access to med information from outside pharmacies
• No one knows what is being done and by who
• Floor nurses do not trust the accuracy of meds by history from the ED- so they
do it over.
• Patients are interrogated multiple times, being asked the same questions
• Patients may not be able to afford meds on discharge d/t new meds
• Not all individuals involved in the patient care are aware of a patient’s discharge
• Med info on d/c is overwhelming
6. Steps involved in completing meds by history
Obtain list from patient
(if lucky)
Verify with patient med,
dose, last taken
Make call to outside
pharmacy, ecf, or family
for clarifications
Enter changes in
Cerner
E
D
Ask patient for home
med list
Review with patient
med, dose, last taken
Place call for
clarifications
Enter any changes in
Cerner
Pt to floor
F
l
o
o
r
7. Initial State - metrics
Metric
Quality
% of med errors discovered through
HF Clinic brown bag session
9.4%
Initial
8. Target State
• HF patients will have an accurate medication history
obtained on admission
• HF patients to receive consistent medication education so
they know how to manage their meds after discharge
9. Target State - metrics
Metric
Quality
% of med errors discovered through
HF Clinic brown bag session
Goal
4.7%
10. Patients who are at highest
risk for medication errors (HF
patients) are not easy to
identify.
• If we create a tool that
would help to identify these
high risk HF patients, then
services specific to their
condition can be
implemented appropriately
and timely.
Gap Analysis Solution Approach
11. [somewhat of a] Rapid Experiment
Work with Darrel to develop a report,
looking at active inpatients (and
observations) who have had a BNP
drawn with a result greater than 100.
If able to create this report, multiple departments would
benefit from this – HF clinic, pharmacy, nursing units, core
measures.
12. The responsibility of
completing medications by
history falls on multiple
people with ill defined roles
or expectations – resulting in
duplication and errors.
Those currently involved in
completing meds by history
are not able to focus 100% of
their attention on ensuring
accuracy or completeness.
• If we create a process
where the role and duties
of completing medications
by history was clearly
defined and performed by
individuals specially
trained in this role, then
there would be less risk of
errors occurring and floor
nurses would not feel the
need to rework the list.
Gap Analysis Solution Approach
13. Rapid Experiment
Have a pharmacy tech in ED to obtain home medication list
from patient, enter medications correctly, and make any
clarifying phone calls. The ED pharmacist will review and
approve the list, enter an order stating “Medications by
History completed by pharmacy” to show up in MAR x 24
hours, and sign meds by history as complete. Interventions
will be documented by the ED pharmacist when further
clarification is needed when patient transitions to floor.
These interventions will be followed up by the unit
pharmacist.
RESULTS:
•ED nurses were very happy that they could focus their
attention on caring for their patients
•Floor nurses felt confident in the information that the
pharmacy entered
•Meds by history was accurate and complete
RESULTS:
•ED nurses were very happy that they could focus their
attention on caring for their patients
•Floor nurses felt confident in the information that the
pharmacy entered
•Meds by history was accurate and complete
14. Patients often leave without
fully understanding how to
manage their medications or
resources available.
• If we create a process
where patients are able to
receive education regarding
medication and
compliance, then patients
will leave the hospital
better prepared to manage
their medications
Gap Analysis Solution Approach
15. Rapid Experiment
After getting the voice of our customers, we identified that
while patients like the current discharge instructions, they
were interested in attending a class while at the hospital.
We were unable to experiment with this, but did develop
curriculum for a HF medication class for inpatients to
attend. This class covers types of meds, compliance, side
effects, drug interactions, and resources/tools available.
This 1hour class would be led by a pharmacist, include
patients and their family members, and occur every
Tuesday and Thursday.
Solution:
16. Investigated ability to alert
physician if completing a
med rec prior to meds by
history being complete.
Explore capability within
Cerner to identify
medications that have not
been verified or confirmed
on the Meds by History.
Investigated
External Rx History
module and ability
to utilize.
Discovered
lots of
‘opportunities
’
Other stuff we did:
Worked with HF
clinic to identify
ways to enhance our
current medication
review process
Worked with HF
clinic to identify
how pharmacy
can help with
HF rounds
17. Parking lot
There were a few things that were identified as actionable
root causes, but were outside the realm of this team to
attempt to conquer.
Not all individuals involved in the
patient’s care are aware of the
plan for discharge
– Collaborative Rounds coming
in June
– recommend including floor
pharmacist
Staff feel rushed to complete meds by history
due to pressure from physicians so the med
rec can be completed.
Report at handoff between ED
RN and floor RN needs to
include status of meds by history
18. Completion Plan
Find location for trial class to take place in Jonna 6/13/14
Find ideal time for class to occur Jonna 6/13/14
Schedule/free up pharmacist to cover class
Wolverine &
Lisa 6/13/14
Train pharmacist to teach class
Wolverine &
Lisa 6/13/14
Get the word out to floors re: HF med class Jonna 6/13/14
Follow up with Shona re: access for ED pharm tech Susan 5/23/14
Continue trialing new ED pharmacy tech position and
gathering further data
Chris, Nate,
Geoff, & Susan ongoing
Follow up with Darrel re: HF identification reports Susan 5/23/14
Follow up re: 3M 360 capabilities for identifying HF
patients Susan 7/1/14
Work with Helen look at other options for the brown bag
process through the HF clinic
Pharmacy &
Helen 6/20/14
Send letters to ECF/PCP re: providing patients with an
updated medication list Lisa 5/23/14
Train pharmacists on motivational counseling Wolverine 7/1/14
Ensure that all those making post-discharge follow up
calls are inquiring about the ability to pay for their meds.
(refer to Melanie if patient repsonds 'no') Susan 5/23/14
Further explore the gaps in the discharge med rec
process
next pass team,
facilitated by
Amanda
TBA post
Core team
meeting
Look at possiblity of giving patients going through brown
bag session or HF med class a med box prior to discharge Susan 6/1/14
Action Who Date Due
20. Insanity:
doing the same thing
over and over again
& expecting DIFFERENT results.
-Albert Einstein
21. Insights
• Every patient we trialed had an error that was able to be
corrected that otherwise could have gone undetected
• Our voice of the customer results were shocking
• Can we ‘TVM’ the government?
• Support from ED and the floors was wonderful
• When you go ask and see, you will find
• Ryan likes his pasta al dente
• Remember to wear clothes when Skyping
• We should invest in an ultrafiltration Bentley
• One of the TVM phases should be NAPTIME
• Excuses to use to get out of a med rec event:
– I’m sick, my wife had a baby, I have an “emergency”
