medication reconciliation


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medication reconciliation

  1. 1. S Photo by Charles Williams - Creative Commons Attribution License Created with Haiku Deck
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  3. 3. S Med Wreck to Med Rec .
  4. 4. What is the problem? S Hospitalized patients who experience an adverse drug event (ADE) are twice as likely to die as those without an ADE (JAMA 1997; 277:301-306) S The Institute of Medicine has estimated that medication errors account for 7,000 deaths annually (To Error Is Human: building a safer health system, 1997, IOM) S ADEs account for 6.3% of malpractice claims (Arch Intern Med. 2002; 162:2414-2420)
  5. 5. Scope of the Problem – Admission Comish, et al. Arch Intern Med. 2005;165:424-9 S 151 patients in a study (at least 4 prescription medications) S 53 % had at least one unintended discrepancy S Omission was the most common error S 38 % of the discrepancies had the potential to cause serious to moderate harm
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  7. 7. What Happened? Swiss Cheese Model of Major Errors Reason J. Human error: models and management. BMJ. 2000;320:768-770. Transcriptio n errorDC meds not reviewed Pt/care giver does not review meds Outpt doc unaware of change Sentinel Event Admission
  8. 8. IOM: To Err is Human 1999- Institute of Medicine’s (IOM) report 98,000 deaths annually in hospitals 1.5 Million Potential ADEs (1/day/pt) 9000 deaths from adverse drug events Most errors are system based, not due to reckless
  9. 9. S Photo by mcmorgan08 - Creative Commons Attribution-ShareAlike License Created with Haiku Deck
  10. 10. S Photo by US Army Africa - Creative Commons Attribution License Created with Haiku Deck
  11. 11. S Photo by gazzat - Creative Commons Attribution-NonCommercial-ShareAlike License Created with Haiku Deck
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  13. 13. S Photo by xavi talleda - Creative Commons Attribution-NonCommercial-ShareAlike License Created with Haiku Deck
  14. 14. A well designed process is: S It uses a patient-centered approach S The process is easy to complete by all involved. Staff recognize the importance S It minimizes opportunity for drug interactions and therapeutic duplications by making the patient’s list of home medications available to all prescribers S It provides the patient with an up-to-date list of medications S It ensures that providers who need to have information about changes in the medication plan get that information 14
  15. 15. Challenges S There is no clear owner of the process. S There is no standardized process to ensure that the patient’s home medication list is available to all providers and compared with the most recent list of medications as patients move through different levels of care S Physicians are reluctant to order medications that may be unfamiliar to them or that have been prescribed by others S Staff do not have the time to complete each of the steps in the process S The focus has been on completing a form rather than meeting the intent of the intervention S There are many situations in which the patient may not know or can’t provide a list of medications. S Accurate sources of information may be difficult to identify S The original medication list isn’t linked to the physician orders as the patient transitions from one location to another. 15
  16. 16. ‘One source of truth’ 16
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  18. 18. PRECEDE-PROCEDE 18
  19. 19. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Act Plan Study Do Adapted from: The Institute for Healthcare Improvement
  20. 20. The PDSA Cycle Act • What changes are to be made? • Next cycle? Plan • Objective • Questions and predictions (why) • Plan to carry out the cycle (who, what, where, when) Study • Complete the analysis of the data • Compare data to predictions • Summarize what was learned Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data
  21. 21. Medication reconciliation program Timeline Month 1 Month 2 Month 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Shadowing on Units Kickoff & Team Orientation Escalation Planning Long Term Action Plan Tracking Live Metric Tracking Plan Do Study Activity Progress Review # 2 Hospital Analyst Training Solution Tracker Updated Weekly Prioritized Solution Implementation Baseline Analyses Complete Quick Win Implementation Progress Review # 1 Solution Prioritization & Planning Solution Development Root Cause Analysis Pain Point Prioritization Pain Point Identification Process Mapping Act/ Sustain Initial Leadership Meetings Baseline Establishment & Goal Setting Prioritized Solution Approval Solution Implementation Issue Identification & Prioritization Sustainability
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  23. 23. Nursing intervention S Education about BPMH S Education about charting in HED S Education about sources of information S Flyers S Champions 23
  24. 24. Physician intervention S Education in doing med rec in 24 hours S High risk meds in 4 hours S On call physician to cooperate S Discrepancy clarification 24
  25. 25. Pharmacy intervention S Educating pharmacist to make changes in HHS S Contacting outside pharmacy S Helping nurses in discrepancy 25
  26. 26. Patient intervention S Signage in ED about bringing home meds S Wallet medication card S Education flyers in the room next to communication boards S Discharge education in regards to PCP. 26
  27. 27. IT intervention S Glitch in system regarding indications, last dose taken etc. S Nurses access to HPF (past medical record) 27
  28. 28. Policy intervention S Clarifying roles in policy S Addition of flow map S Addition of high risk medication rule. 28
  29. 29. Outcome S The measurable outcomes of the program are: S Increased staff and patient satisfaction. S Reduced readmission rates secondary to medication reconciliation. S Increased communication with PCP at discharge. S Reduced adverse drug events causing harm to the patient secondary to prevention of medication errors. S Medication reconciliation completed 100% of the time and addressed by MD within 24 hours. S Zero discrepancy in the home medication list. S Nurses able to interview patient regarding the BPMH. S Secondary outcomes include reduced cost, increase quality of life, adequate refills etc. 29