1. Medication Reconciliation & Presenter Name & Organization
Medication Safety
The Role of
Medication Reconciliation &
Medicine Lists
Presenter Name & Organization

2. Objectives Be familiar with Washington Patient Safety Coalition
Understand where medication reconciliation, My Medicine List, and safe transitions fit into the medication safety strategic plan.
Understand the current regulatory drivers around medication reconciliation, such as The Joint Commission’s National Patient Safety Goal (NPSG)
Advocate and implement medication reconciliation into workflow
Promote patient awareness and utilization of My Medicine List

3. Patient Case
52 year old man goes to the clinic for a check-in visit with his Specialist provider.
Patient’s electronic chart indicated he was to take 1 tablet of aspirin 325 daily.
Patient reported taking 18 tablets of aspirin 325mg daily for shoulder pain.
MEG
This patient had not had the opportunity yet to tell a healthcare professional how much aspirin he was taking until the medical assistant walked through his medication list with him.
When the discrepancy was identified, it was sent to a med reconciliation pharmacist for review
The pharmacist called the patient
The patient did not know that it was a very dangerous daily dose of aspirin (well over the recommended maximum of 400%)
The patient had never told his doctor that he was taking that much
The pharmacist determined that acetaminophen was a safer choice for this patient
The pharmacist gave him a recommended dosing plan with acetaminophen
If this patient continued to take 6,000 mg of aspirin daily, he was great increasing his chance of bleed.
The patient learned the importance of knowing his medications and following his recommended medication list.
He also learned to tell his healthcare professionals exactly what he was taking.
This is almost 6,000 mg of Aspirin
New pain regimen was discussed

4. About the WPSC www.wapatientsafety.org
The Washington Patient Safety Coalition is dedicated to improving patient safety and reducing medical errors for individuals receiving health care in Washington, in all care settings.
Our Vision
Safe care: every patient, every time, everywhere.
Our Values
Patient-centered
Systems-oriented and sustainable
Evidence-based
Inclusive
Resource-sensitive
Our Goals
We will improve safety within and across all care settings by:
Facilitating the exchange of information about best practices relative to patient safety.
Disseminating new knowledge and new practices.
Supporting coordinated/collaborative efforts and new partnerships.
Raising awareness of the need for safe practices.
Our Values
Patient-centered: The methods used and promoted by the Coalition will be driven by the needs of the patient.
Systems-oriented and sustainable: The Coalition will focus on system changes that create and sustain a safe environment.
Evidence-based: The Coalition will strive to promote methods and activities that are evidence-based, while accommodating new research and emerging applications.
Inclusive: The Coalition’s work will recognize the diversity of our community and will strive to include all populations.
Resource-sensitive: The Coalition will be sensitive to the resources required to implement and sustain change.

5. The Concerns Around Medication Safety
1999 IOM report: estimated that medical errors cause 44,000 to 98,000 preventable deaths and one million additional injuries each year in U.S. hospitals, and cost over $850 billion.
A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, each year…
400,000 preventable drug-related injuries occur in hospitals
800,000 in long-term care settings
530,000 among Medicare recipients in outpatient clinics

6. Improving Medication Safety: Where to begin?
Drug Interactions
High Alert /
High Risk Agents
Adherence/ Compliance Barriers
Patient Education
Improved Packaging & Labeling
Medication Errors
Prescriber Education
Transitional Care Management
Transitional Care Management

7. Patients at Risk
Nearly 40% of patients have ≥ 1 unintended medication discrepancy at hospital admission!
A similar proportion are present at transfer within a hospital and in 14% of patients at hospital discharge.
A series of interventions, including medication reconciliation, introduced over a seven-month period, successfully decreased the rate of medication errors by 70% and reduced adverse drug events by over 15%. Whittington J, Cohen H. OSF Healthcare’s Journey in Patient Safety. Quality Management in Health Care. 2004;13(1):53-59.
Cornish PL et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:

8. Medication Reconciliation:
A Definition?
No standard exists! The Joint Commission recommends…
The process of verifying that a patient’s current list of medications (including dose, route, and frequency) is correct and that the medications are currently medically necessary and safe.
Greenwald et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Jt Comm J Qual Patient Saf Nov;36(11):504-13, 481.

9. ASHP-APhA Medication Reconciliation Goals
Medication reconciliation should be a patient-centered process, taking into account the patient’s level of health literacy and willingness to engage in his or /her personal health care.
Target improvement in patient well-being through education, empowerment, and active involvement
Achieve by promoting communication among patients and healthcare providers
ASHP – APhA Medication Reconciliation Initiative Workgroup Meeting . February 12, 2007

10. Achieving Medication Safety Goals via Medication Reconciliation
Drive Systems (Re)Design
and Process Improvement
Drive Systems (Re)Design
and Process Improvement
Catalyst Driving Change
WPSC
Regulatory Organizations
Reimbursement Models
Maximize Use of Technology
Facilitate Cultural Change

11. Healthcare Systems Design: Must Support the Med Rec Process
Collect
Clarify
Change in…
Care Setting
Medications
Verify
Reconcile
Communicate
Educate

12. Medication Reconciliation: Not So Simple!
DISCHARGE PROCESS
HOSPITAL ADMISSION PROCESS
COMMUNITY PROCESS
Medication
Info Sources
Pt & Family
Clarification/Verification
Physicians
Pharmacies
Pre-Admit Outpt Medication List
Pre-Admit Outpt Medication List
Pre-Admit Outpt Medication List
Pt & Family
Care Facilities
Physicians
Outpatient Medication List
Pharmacies
Medical Records
Inpatient Med List
Inpatient Med List
Care Facilities
3rd Party Vendors
Patient condition & diagnosis
Discharge Medication Reconciliation

13. Real Life Example: Inpatient Admission
Patient admitted through ED
ED Not a good setting for collecting information
Triage, stabilize, transfer or discharge
Solution: ED Med Rec Techs
Complete when admitted on unit?
Nurses busy admitting patient
Med Rec challenging and time consuming
Use what was collected in ED? Verify but not thoroughly?
Provider prints off what is in system
Unverified, from last admission
Errors perpetuated on Transfer and at Discharge
Garbage In = Garbage Out
Example of process at Franciscan Health System

14. Real Life Example: Franciscan Health System
Patient Arrives at ED
ED Med Rec Tech
Interviews patient or caregivers
Records medication information from patient medication bottles
Calls outpatient pharmacies, queries available sources, GH Epic, FMG Elysium, etc., contacts patient’s PCPs
Clarifies information with family or caregiver
Generates a complete and accurate home med list that is reviewed by a pharmacist
List provided to ED or admitting provider to complete medication reconciliation.
Accurate home medication improves transitions in care
Provides a good foundation for Discharge Med Rec
Example of improved process from Franciscan Health System

15. Real Life Example: Group Health
Post-Discharge Medication Reconciliation
Discharge
Home
Primary Care
Example provided by Group Health
Patients identified who are high risk for readmit
Information sent to Clinical Pharmacists for follow up
Pharmacist calls patient days post-discharge
Med recon and comprehensive medication review
Pharmacist updates patient’s physician
Makes medication
recommendations
80% of patients have at least
one discrepancy resolved.

16. Safe Transitions Involve Many!
Safe transitions are best when we maximize a
multi-disciplinary approach
Group Health: Specialty Medication Reconciliation involves a variety of disciplines
Medical Assistant: medication verification
Specialist: medication review and hand-off to pharmacist
Pharmacist: comprehensive medication reconciliation and communication to patient and appropriate physicians
Primary Care Provider: authorize prescriptions and carry out ongoing care of patient’s therapy
Group Health’s Multidisciplinary approach to specialty medication reconciliation

17. Incentivizing Change via Regulatory Process
Mandating change and prioritization
Technology Adoption

18. Medication Reconciliation Requirements
The Joint Commission
Medication Reconciliation Requirements
A 6-year journey to improve patient safety
2005
2006
2007
2008
2009
2010
2012
TJC
introduces
NPSG 8
“Med Rec” required for accreditation
NPSG
minor revisions
NPSG major revisions planned
Scoring suspended and some simplification
New standards created & released
Implementation of new standard

19. Medication Reconciliation
TJC 2011
Medication Reconciliation
National Patient Safety Goal #3: “Improve the safety of using medications”
NPSG : “Maintain and communicate accurate patient medication information”
Applies to:
Hospitals, including Critical Access Hospitals
Ambulatory Care
Office (Ambulatory) Surgery
Home Care
Long-term Care
Behavioral Health
TIM

20. The Patient Protection and Affordable Care Act (H.R. 3590)
Value-Based Purchasing (VBP)
Hospital Consumer
Assessment of Healthcare
Providers and Systems (HCAHPS)
(Section 3001)
Core Measures
(Section 3001)
Healthcare-Associated
Infections (HAI)
(Section 3001)
At Risk: 1% in FY2013 growing annually to 2% in FY2017
(70% Core Measures + HAI and 30% HCAHPS)
Medicare Reimbursement
TIM
Effective Oct. 1, 2012
Reduces Medicare inpatient payments for hospitals with higher than expected risk-adjusted readmission rates for certain conditions.
Reduced Medicare payments for every discharge.
At Risk: 1% reduction
beginning FY2015
At Risk: 1% reduction in FY2013 and will
Rise to 3% by FY2015
Hospital Acquired
Conditions (HAC)
(Section 3008)
Readmission Rates
(Section 3025)
AMI, PNE, HF
COPD, CABG,
PTCA, etc. 5

21. Readmissions are…
Frequent
18% of all Medicare hospitalizations are 30-day re-hospitalizations
Average rates are >20% for certain patient populations
Potentially avoidable
76% of Medicare re-hospitalizations were “potentially preventable”
Costly
$15B annually in Medicare of which $13B may be unnecessary
Actionable for improvement
Research and quality improvement initiatives have demonstrated >30% reduction of 30-day readmission rates for a variety of populations
Medications and medication use are often implicated in unexpected readmissions!
MedPAC 2007 Report to Congress; Promoting Greater Efficiency in Medicare

22. Med Reconciliation & Readmissions
How much does a
hospital readmit cost?
$14,500
Our analysis shows
that for every 25
patients that receives
med recon post-
discharge, 1 hospital
readmit is prevented.
Group Health data. The $14,500 is the approximate cost of a readmission (or an admission).
For the 2012 calendar
year, the program will
save an estimated
1 million dollars
14 day
30 Day
Kilcup M, Schultz D, et al. Post-discharge pharmacist medication reconciliation: Impact on readmission rates and financial savings. J Am Pharm Assoc. 2013: Jan/Feb, 53:1.

23. Opportunities for Pharmacy: Readmissions Preventing Interventions
Phase of Care
Admission
Inpatient Stay
Discharge
Home
Pharmacy Service Provided
Perform Admission Assessment
Determine factors in admission/readmission
Medication history
Medication reconciliation
Errors of omission (EBM)
Adverse drug events (ADE)
Medication adherence
Medication access
Determine post-hospital needs
Where will patient likely receive care?
Who are caregivers?
Barriers to care?
Care Optimization
Provide effective teaching & enhanced learning
Identify barriers to learning
Medication management
Disease self-management
Medication adherence
Use “Teach Back” method
Provide tools
Optimize the medication regimen
Initiate indicated medications
Discontinue unnecessary or unsafe medications
Simplify the medication regimen
Prepare for Transition in Care
Medication regimen review
Medication reconciliation
Provide medication list and related information to:
Patient/caregiver
Physician/medical team
Pharmacy/pharmacist
Verify appropriate post-discharge care plan
Match discharge follow-up to need (readmission risk stratification)
Ensure proper information is provided regarding contact information, action plan for care and symptom or AE management
Provide Appropriate Post-Discharge Care
Contact patient/caregiver
Live or virtual visit
Patient status and medication review
Medication reconciliation
Medication adherence
ADE surveillance
Medication access
Med management/ Disease management
Communicate to other providers any pertinent medical information or findings

24. Achieving Medication Safety Goals via Medication Reconciliation
Drive Systems (Re)Design
and Process Improvement
Catalyst Driving Change
WPSC
Regulatory Organizations
Reimbursement Models
Maximize Use of Technology
Maximize Use of Technology
Facilitate Cultural Change

25. Achieving Medication Safety Goals via Medication Reconciliation
Drive Systems (Re)Design
and Process Improvement
Catalyst Driving Change
WPSC
Regulatory Organizations
Reimbursement Models
Maximize Use of Technology
Facilitate Cultural Change
Facilitate Cultural Change

26. “My Medicine List”
A WPSC Sponsored Project

27. My Medicine List Heighten Public Awareness
Emphasize the need for patients to take an active role in managing their medicines.
The initiative’s goal is for every person to maintain an up-to-date list and to share it with his/her health care provider.
TIM
A campaign intended to build public awareness of the need for patients to take an active role in managing their medicines.
Sponsored by the Washington Patient Safety Coalition (WPSC)
The initiative’s goal is for every person to maintain an up-to-date list of every medicine he or she is using and to share it with his or her health care provider during each and every visit.

28. My Medicine List
A sample of resources available on the My Medicine List pages of the WPSC web site.

29. What's in a “Medicines” List
Prescription medications
Sample medications
Vitamins
Herbal & Alternative Meds
Nutriceuticals & Dietary Supplements
Over-the-counter drugs
Vaccines
Respiratory therapy-related medications
Parenteral nutrition
Blood derivatives
Intravenous solutions (plain or with additives)
Diagnostic and contrast agents
Radioactive medications
Any product designated by the FDA as a drug!

30. How Can You Help? Remember the 3 As
ASK every patient about his or her medicine list at each encounter.
ADVISE your patients to carry a list
ASSIST your patients with resources & tools
Refer your patients to mymedicinelist.org
for information and resources
What you don’t know about your patients could harm them!

31. Thank You!