Medicines Reconciliation Needs You!


Published on

This session will introduce delegates to medicines reconciliation and its role in reducing the opportunity for error and harm to patients by making sure they are given the right medicines at every stage of their care.

Published in: Health & Medicine, Business
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • How many opportunities hold up your numbers Please. This is my journey and I have identified 11 Each patients journey will be different but, there are common aspects such as
  • This is why do we need medicines reconciliation. One example One too many
  • Lucian leape
  • Take your FMEA sheets we are going to concentrate on the first 3 columns
  • Medicines Reconciliation Needs You!

    1. 1. Medicines Reconciliation Needs YOU! Jennifer Ross Medication Safety Officer SPSP Fellow
    2. 2. Aims: <ul><li>For everyone to enjoy the session and participate. </li></ul><ul><li>To provide a general introduction to medicines reconciliation. </li></ul><ul><li>To consider the patient journey as a process. </li></ul><ul><li>To establish the role of medicines reconciliation in reducing avoidable harm. </li></ul><ul><li>To demonstrate how FMEA as an improvement tool can improve the quality of a process. </li></ul><ul><li>Delegates will have an understanding of FMEA and have a plan of how they will use it to improve medicines reconciliation for patients. </li></ul>
    3. 4. What is Medicines Reconciliation? <ul><li>‘ the process of identifying the most accurate list of a patient’s current medicines — including the name, dosage, frequency, and route — and comparing them to the current list you are working from. This enables any discrepancies to be recognised and changes documented, thereby resulting in a complete list of medications, accurately communicated. ’ </li></ul><ul><li>Institute of Health Improvement </li></ul>
    4. 6. Group work 1. <ul><li>Consider Mr CeeCee’s Journey and work out how many transitions occur where Medicines reconciliation should have been done. You have 5 minutes to introduce yourselves at your table and decide as a group how many times medicines Reconciliation should have been undertaken. </li></ul>
    5. 7. Patient Journey as a process. Patient is admitted to A&E due to a collapse whilst out shopping Patient is transferred to community hospital Discharged home Patient is stabilised and transferred to acute assessment Unit. Patient deteriorates and is transferred to ITU Patient is transferred to HDU Patient is transferred to ward Seen by diabetes specialist as OP Seen by community pharmacist for self care advice Seen by out of hours service Seen by cardiology as OP
    6. 8. Patient notes / communication of information <ul><li>Patient / Relative </li></ul><ul><li>Vision </li></ul><ul><li>A&E record </li></ul><ul><li>Inpatient notes (how many types of prescription chart in your board) </li></ul><ul><li>Transfer letter </li></ul><ul><li>Community hospital notes </li></ul><ul><li>Discharge letter </li></ul><ul><li>Temporary set of notes </li></ul><ul><li>Community Pharmacist record </li></ul><ul><li>OOH records (ADASTRA) </li></ul><ul><li>Inpatient/Temporary notes </li></ul>
    7. 9. Medicines Reconciliation to reduce avoidable harm. <ul><li>Inadequate medicines reconciliation accounts for up to 20% of adverse drug events and 46% of all medication errors among hospital inpatients. </li></ul><ul><li>(Roizic 2001) </li></ul><ul><li>Ensuring that medicines reconciliation is carried out by a pharmacist (De Winter et al, Clay et al, Gleason et al) </li></ul><ul><li>Forming strategies to focus on the introduction of an electronic record (Green et al) </li></ul>
    8. 10. July 2009
    9. 11. October 2008
    10. 13. Failure Modes Effects Analysis (FMEA) <ul><li>FMEA is a pro-active improvement tool that provides a systematic method of evaluating a process by: </li></ul><ul><li>Identifying where and how it might fail </li></ul><ul><li>Assessing the relative impact of different failures </li></ul><ul><li>Identifying the parts of the process most in need of improvement. </li></ul>
    11. 14. How to carry out an FMEA
    12. 15. Process. <ul><li>Be clear what you are looking at. </li></ul><ul><li>Break the process down into steps. </li></ul><ul><li>Be structured and methodical. </li></ul><ul><li>Medicines reconciliation on admission. </li></ul><ul><li>From home as an unscheduled admission. </li></ul>
    13. 16. Definitions. <ul><li>Failure Mode – What could go wrong? </li></ul><ul><li>Cause – Why would it go wrong? </li></ul><ul><li>Effects – What would be the consequences of failure? </li></ul>
    14. 17. Step 1. 1.Unable to communicate with patient. 1.1 Patient is unconscious 1.2 Language barrier 1.3 Patient choice or condition Incomplete information Possible harm to patient Use of language line Local protocol relating to unconscious patient
    15. 18. Group work 2. <ul><li>What other failure modes can you think of relating to our process step? </li></ul><ul><li>At your tables think about and document the causes of 1 or 2 failure modes and what the effects would be. </li></ul><ul><li>Time to Score! </li></ul>
    16. 19. 1.Unable to communicate with patient. 1.3 Patient choice or condition 1.1 Patient is unconscious 1.2 Language barrier Incomplete information Possible harm to patient Incomplete information Possible harm to patient Incomplete information Possible harm to patient 7 5 1 10 50 7 3 10 210 Ensure a minimum of 2 sources of information are used for medicines reconciliation. 1 10 70 7 x 1 x 10 =
    17. 20. Thank you for participating Any Questions? [email_address] 01224 551570