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. 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
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. 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. S
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10. S
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11. S
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12. S
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13. S
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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. 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
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. 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. 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
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. 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. Pharmacy intervention
S Educating pharmacist to make changes in HHS
S Contacting outside pharmacy
S Helping nurses in discrepancy
25
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. IT intervention
S Glitch in system regarding indications, last dose taken
etc.
S Nurses access to HPF (past medical record)
27
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
