What is the problem?
S Hospitalized patients who experience an adverse drug
event (ADE) are twice as likely to die as those without an
(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;
Scope of the Problem –
Comish, et al. Arch Intern Med. 2005;165:424-9
S 151 patients in a study (at least 4 prescription
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
Swiss Cheese Model of Major Errors
Reason J. Human error: models and management. BMJ. 2000;320:768-770.
n errorDC meds not reviewed
Pt/care giver does not
IOM: To Err is Human
1999- Institute of Medicine’s
98,000 deaths annually in
1.5 Million Potential ADEs
9000 deaths from adverse
Most errors are system
based, not due to reckless
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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
S It ensures that providers who need to have information
about changes in the medication plan get that information
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
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.
What are we trying to
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Model for Improvement
Adapted from: The Institute for Healthcare Improvement
The PDSA Cycle
• What changes
are to be made?
• Next cycle?
• Questions and
• Plan to carry out
the cycle (who,
what, where, when)
• Complete the
analysis of the data
• Compare data to
• Summarize what
• Carry out the plan
• Document problems
• Begin analysis
of the data
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
Long Term Action Plan Tracking
Live Metric Tracking
Plan Do Study
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
Root Cause Analysis
Pain Point Prioritization
Pain Point Identification
Initial Leadership Meetings
Baseline Establishment & Goal Setting
Prioritized Solution Approval
Issue Identification & Prioritization
S Education about BPMH
S Education about charting in HED
S Education about sources of information
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
S Educating pharmacist to make changes in HHS
S Contacting outside pharmacy
S Helping nurses in discrepancy
S Signage in ED about bringing home meds
S Wallet medication card
S Education flyers in the room next to communication
S Discharge education in regards to PCP.
S Glitch in system regarding indications, last dose taken
S Nurses access to HPF (past medical record)
S Clarifying roles in policy
S Addition of flow map
S Addition of high risk medication rule.
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.