Spotlight Case November 2005 Reconciling Doses

Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico , RPh , Director, Institute for Healthcare Improvement Editor, AHRQ WebM&M: Robert Wachter, MD Spotlight Editor: Tracy Minichiello, MD Managing Editor: Erin Hartman, MS

This presentation is based on the November 2005 Spotlight Case in Emergency Medicine

See the full article at http://webmm.ahrq.gov

CME credit is available through the Web site

Commentary by: Frank Federico , RPh , Director, Institute for Healthcare Improvement

Editor, AHRQ WebM&M: Robert Wachter, MD

Spotlight Editor: Tracy Minichiello, MD

Managing Editor: Erin Hartman, MS

Objectives At the conclusion of this educational activity, participants should be able to: List the steps involved in medication reconciliation Describe the role of each of the stakeholders in medication reconciliation Discuss how medication reconciliation decreases the opportunity for medication errors and harm

At the conclusion of this educational activity, participants should be able to:

List the steps involved in medication reconciliation

Describe the role of each of the stakeholders in medication reconciliation

Discuss how medication reconciliation decreases the opportunity for medication errors and harm

Case: Reconciling Doses A 68-year-old man with a history of diabetes and atrial fibrillation (maintained on warfarin) presented to the emergency department (ED) with fever and mental status change. Lumbar puncture was attempted three times without success; empiric treatment for meningitis was started. Further examination revealed an area of cellulitis, and intravenous antibiotic therapy was changed accordingly.

A 68-year-old man with a history of diabetes and atrial fibrillation (maintained on warfarin) presented to the emergency department (ED) with fever and mental status change. Lumbar puncture was attempted three times without success; empiric treatment for meningitis was started. Further examination revealed an area of cellulitis, and intravenous antibiotic therapy was changed accordingly.

Case (cont.): Reconciling Doses At the time of admission, the patient was unable to recite his medication list, and his wife was unclear about the doses. However, the EMS run-sheet had a list of the patient’s medication and doses. The patient was started on the medication regimen per the EMS report.

At the time of admission, the patient was unable to recite his medication list, and his wife was unclear about the doses. However, the EMS run-sheet had a list of the patient’s medication and doses. The patient was started on the medication regimen per the EMS report.

Medication Reconciliation The process of collecting the best medication history possible, verifying that list, and comparing it with orders written at admission, transfer, and discharge Ensures each member of health care team has access to a list of home medications and what was ordered at transitions in levels of care Provides a method to communicate when an intentional medication change is made

The process of collecting the best medication history possible, verifying that list, and comparing it with orders written at admission, transfer, and discharge

Ensures each member of health care team has access to a list of home medications and what was ordered at transitions in levels of care

Provides a method to communicate when an intentional medication change is made

Medication Reconciliation: The Data More than one half of medication errors occur at the interfaces of care Up to 67% of cases had errors in prescription medication histories An average of 10 prescriptions needed to be changed weekly in the ICU as a result of implementing a reconciliation process Rozich JD, Resar RK. JCOM. 2001;8(10):27-34. Tam VC, et al. CMAJ 2005;173:510-515. Pronovost P. J Crit Care. 2003;18:201-205.

More than one half of medication errors occur at the interfaces of care

Up to 67% of cases had errors in prescription medication histories

An average of 10 prescriptions needed to be changed weekly in the ICU as a result of implementing a reconciliation process

Medication Reconciliation Recommended change for teams participating in IHI collaboratives to reduce adverse drug events One of six changes chosen by the 100,000 Lives Campaign to improve patient care and prevent avoidable deaths JCAHO selected medication reconciliation as one of the National Patient Safety Goals 100K Lives Campaign. IHI Web site. National Patient Safety Goals for 2006 and 2005. JCAHO Web site.

Recommended change for teams participating in IHI collaboratives to reduce adverse drug events

One of six changes chosen by the 100,000 Lives Campaign to improve patient care and prevent avoidable deaths

JCAHO selected medication reconciliation as one of the National Patient Safety Goals

Case (cont.): Reconciling Doses After 2 days, the patient was transitioned to Augmentin. While in hospital, the patient had been receiving 5 mg of warfarin at bedtime, which, according to the EMS intake sheet, was his usual outpatient dose. The team did not confirm this dose with the patient’s family, primary physician, or pharmacy.

After 2 days, the patient was transitioned to Augmentin. While in hospital, the patient had been receiving 5 mg of warfarin at bedtime, which, according to the EMS intake sheet, was his usual outpatient dose. The team did not confirm this dose with the patient’s family, primary physician, or pharmacy.

Case (cont.): Reconciling Doses At the time of discharge, the patient’s INR was noted to be 4. Realizing the warfarin dose was too high, the team instructed him to decrease his dose to 3 mg at bedtime and to have his INR rechecked in 3 days. After 3 days, his INR was 10. He was treated with vitamin K.

At the time of discharge, the patient’s INR was noted to be 4. Realizing the warfarin dose was too high, the team instructed him to decrease his dose to 3 mg at bedtime and to have his INR rechecked in 3 days. After 3 days, his INR was 10. He was treated with vitamin K.

Case (cont.): Reconciling Doses Two days later, the patient returned to the ED with back pain, lower extremity weakness, and incontinence. He was found to have an epidural hematoma. The hematoma was emergently evacuated. One week post-operatively, the patient still had neurologic deficit.

Two days later, the patient returned to the ED with back pain, lower extremity weakness, and incontinence. He was found to have an epidural hematoma. The hematoma was emergently evacuated. One week post-operatively, the patient still had neurologic deficit.

Starting a Medication Reconciliation Program Identify a champion and a multidisciplinary team to work on testing changes that will lead to the desired system Ensure senior leadership support Secure commitment for resources for the project during its development Start with a small sample of the hospital population

Identify a champion and a multidisciplinary team to work on testing changes that will lead to the desired system

Ensure senior leadership support

Secure commitment for resources for the project during its development

Start with a small sample of the hospital population

Recruiting Medication Reconciling Team Multidisciplinary team should include: Executive sponsor Physician champion Nursing leader, staff nurse Pharmacy leader, pharmacy support Patient safety/QI representative Staff education representative Other group representatives (see form) Team planning form available here Massachusetts Coalition for the Prevention of Medical Errors.

Multidisciplinary team should include:

Executive sponsor

Physician champion

Nursing leader, staff nurse

Pharmacy leader, pharmacy support

Patient safety/QI representative

Staff education representative

Other group representatives (see form)

Team planning form available here

Examine the system currently in place Use high-level flow diagram to determine the different entry points into the hospital Use similar diagram for transfers and discharges Use a proven improvement methodology (eg, Model for Improvement) to test and implement changes Developing a Medication Reconciliation Program Plsek PE. Pediatrics. 1999;103 (suppl):203-214. Model for Improvement. IHI Web site.

Examine the system currently in place

Use high-level flow diagram to determine the different entry points into the hospital

Use similar diagram for transfers and discharges

Use a proven improvement methodology (eg, Model for Improvement) to test and implement changes

Developing the Reconciliation Process Identify who should participate in each step and define the responsibility of each position Medication history can be completed by a physician, nurse, pharmacist, or pharmacy technician Base decision on available resources Pharmacists found to be more effective in taking medication history but may train others to do so Michels RD, Meisel SB. Am J Health Syst Pharm. 2003;60:1982-1986. Nester TM, Hale LS. Am J Health Syst Pharm. 2002;59:2221-2225.

Identify who should participate in each step and define the responsibility of each position

Medication history can be completed by a physician, nurse, pharmacist, or pharmacy technician

Base decision on available resources

Pharmacists found to be more effective in taking medication history but may train others to do so

Potential Reconciliation Model RN collects medication history Pharmacist verifies information Physicians use the list to aid in decisions about drug therapy and document reasons to discontinue, change, or hold medications

Medication Reconciliation Forms Most organizations use forms Often adapted to serve as order form Columns can indicate whether medication should be continued, discontinued, or placed on hold Place the list prominently in the chart or use colored paper to facilitate access to information Hospitals must determine if these changes introduce new opportunities for errors

Most organizations use forms

Often adapted to serve as order form

Columns can indicate whether medication should be continued, discontinued, or placed on hold

Place the list prominently in the chart or use colored paper to facilitate access to information

Hospitals must determine if these changes introduce new opportunities for errors

Example Reconciliation Form http://www.macoalition.org/Initiatives/RecMeds/CooleyDickinsonReconcilForm.doc

Example Form (cont.) http://www.macoalition.org/Initiatives/RecMeds/CooleyDickinsonReconcilForm.doc

Another Reconciliation Form http://www.macoalition.org/Initiatives/RecMeds/CaritasNorwoodReconcilForm.doc

Another Form (cont.) http://www.macoalition.org/Initiatives/RecMeds/CaritasNorwoodReconcilForm.doc

More Example Forms and Tools Massachusetts Coalition for the Prevention of Medical Errors Reconciling medication toolkit Institute for Healthcare Improvement Medication reconciliation tools

Massachusetts Coalition for the Prevention of Medical Errors

Reconciling medication toolkit

Institute for Healthcare Improvement

Medication reconciliation tools

Medication Reconciliation: Technology Linking electronic medical records to download medication histories onto a form reduces the number of steps and the need to manually complete form At discharge, reformatting the medication profile from the pharmacy system onto a prescription form can efficiently generate discharge prescriptions

Linking electronic medical records to download medication histories onto a form reduces the number of steps and the need to manually complete form

At discharge, reformatting the medication profile from the pharmacy system onto a prescription form can efficiently generate discharge prescriptions

Evaluate Reconciliation Success Use a measurement strategy to determine program’s effectiveness Assessment form available here Collecting data per admission or chart may help determine if reconciliation is occurring Information about the percent of unreconciled medications at different transfer points can identify how well the process is working

Use a measurement strategy to determine program’s effectiveness

Assessment form available here

Collecting data per admission or chart may help determine if reconciliation is occurring

Information about the percent of unreconciled medications at different transfer points can identify how well the process is working

Medication Reconciliation: Role of the Patient Patients can be active participants in medication reconciliation Organizational level: One health system has engaged patients in developing a statewide universal medication form Individual level: Carry up-to-date medication list and present it at each health care visit Patient medication card available here Medication Reconciliation can Save Your Life. McLeod Health Web site.

Patients can be active participants in medication reconciliation

Organizational level: One health system has engaged patients in developing a statewide universal medication form

Individual level: Carry up-to-date medication list and present it at each health care visit

Patient medication card available here

How to Perform Medication Reconciliation Collect the best medication list possible If patient is unable to provide list, interview family members and contact primary physician or local pharmacy Complete medication reconciliation at each transition of care At discharge, reconcile prescriptions with most recent inpatient orders and patient medication list prepared at admission

Collect the best medication list possible

If patient is unable to provide list, interview family members and contact primary physician or local pharmacy

Complete medication reconciliation at each transition of care

At discharge, reconcile prescriptions with most recent inpatient orders and patient medication list prepared at admission

Take-Home Points Medication reconciliation is an effective process to reduce errors and harm associated with loss of medication information at transitions in care Collect the 'best' medication history possible; use open-ended questions when taking a medication history Patients can play a vital role in this process by carrying up-to-date medication list

Medication reconciliation is an effective process to reduce errors and harm associated with loss of medication information at transitions in care

Collect the 'best' medication history possible; use open-ended questions when taking a medication history

Patients can play a vital role in this process by carrying up-to-date medication list

Take-Home Points Hospitals should develop medication reconciliation processes based on patient entry points and available resources Medication reconciliation should be applied whenever medication orders are rewritten or whenever there is a change in treatment plan or level of care For medication reconciliation to be successful, all stakeholders must be involved

Hospitals should develop medication reconciliation processes based on patient entry points and available resources

Medication reconciliation should be applied whenever medication orders are rewritten or whenever there is a change in treatment plan or level of care

For medication reconciliation to be successful, all stakeholders must be involved