1. Lessons from the High 5s Project
Margaret Duguid
Former Pharmaceutical Advisor
Helen Stark
Senior Project Officer
14 November 2014

2. Overview Background and goals Project methodology Lessons learned
Australian results
National Safety and Quality Standard 4 – Medication Safety
In this session I am going to provide some of the background to the High 5s project and the aims of the project. Talk a bit about the methodology used and the lessons learned from participating in the project from the Australian and international perspective and how this work aligns with the National Safety and Quality Standard 4 - Medication Safety. Then Helen will discuss the evaluation component of the project and present the Australian results and outputs from the project.

3. Funded WHO, AHRQ, Commonwealth Fund 5 year project
WHO High 5s Project
Established by WHO in 2007
International collaborative WHO, Joint Commission International and 9 countries
Australia, Canada, Germany, France, The Netherlands, Singapore, Trinidad & Tobago, UK, USA
Funded WHO, AHRQ, Commonwealth Fund
5 year project
The High 5s project was launched by WHO in 2007 to facilitate the implementation and evaluation of standardised patient safety solutions in the form of Standard Operating Protocols (SOPs) within a global learning community.
It is a international collaborative of WHO, the Joint Commission International and nine countries, funded by WHO, the US Agency for HealthCare Research and Quality and the Commonwealth Fund.
The assumption tested in the project was that process standardisation , with minimal variation will improve patient safety. It was a 5 year project.

4. WHO High 5s Project
Aim
Determine feasibility of implementing Standard Operating Protocols (SOPs) in no. countries, healthcare environments
Assess impact on patient safety
The aim was to assess whether it was feasible to implement SOPs in different countries with different healthcare environments and cultures and determine whether the SOP improved patient safety.
That is
Was it possible to standardize on this scale?
If so, will it measurably improve patient safety.
Slide 1 of 14

5. Standard Operating Protocols (SOPs)
WHO High 5s Project
Standard Operating Protocols (SOPs)
Correct procedure at correct body site
Medication accuracy at transitions of care (medication reconciliation)
Concentrated injectable medicines
Countries could select from three SOPs.
Performing correct procedure at the correct body site
Assuring medication accuracy at transitions of care through process of medication reconciliation
Managing concentrated injectable medicines.
Australia opted to participate in the Assuring medication accuracy at transitions of care SOP

6.
Canada was the lead country for the Medication Reconciliation project with the Institute of Safe Medication Practice Canada coordinating the project for the Canadian Patient Safety Institute .
Australia, France, and the Netherlands commenced their implementations in The USA and Germany joined in 2013.
Unlike Australia , Canada and the US , where medication reconciliation was practiced in many hospitals it was a new concept for the European countries.

7. Face to face meetings – 2 x year Monthly teleconferences
Project oversight
Internationally
High 5s Steering Group
Face to face meetings – 2 x year
Monthly teleconferences
High 5s website
E- bulletin for High 5s hospitals
Webinars
International hospital meeting
Nationally
Medication Continuity Expert Advisory Group
Internationally project oversight was provided by a steering group representing all collaborating members. The group met face to face twice a year and monthly by teleconference. These meetings provided a forum for the countries to share experiences. All project materials, SOPs, implementation resources and results were posted on a High 5s project website. An e- bulletin was published with countries sharing their experiences. Webinars were conducted on various Med rec related topics for hospitals and in 2012 an international meeting was held in Geneva that all participating hospitals were invited to attend.
The Australian arm of the project was guided by the Commission’s Medication Continuity EAG.

8. Medication reconciliation SOP
So what was in the Medication Reconciliation SOP? The SOP provided some background to the patient safety problem and medication reconciliation as a solution, the process to be followed and the methodology for implementing the process.

9. Medication errors at transfer of care – the problem
Discharge orders
41% patients had ≥ 1 discrepancy
23% omissions5
Readmission 2.3 x more likely if ≥ 1 med omitted6
Medication orders
30 – 70% patients had discrepancies
Between history and admission orders3
Admission 1
Discharge
Admission Histories
10 -67% contain errors1
Up 1/3 errors PADE2
Internal transfer
62% patients had ≥ 1 unintentional discrepancy
36% PADE4
The problem. By the mid to late 2000s researchers were showing that interfaces of care were prone to medication error and adverse medicines events and accounted for around 50% of hospital medication errors.1 These errors occurred when medication histories were taken on admission and when Medicines were ordered on admission, when patients were transfer from one unit to another (particularly when patients were transferred from a higher level of care (e.g. ICU) and on discharge home or to another facility. The potential for adverse events was significant.
1. Sullivan C, Gleason KM et al J Nurs Care Qual 2005;20:95-8
1. Tam VC, Knowles SR et al, CMAJ 2005
2. Cornish PL, Knowles SR, Archives Int Med NICE NPSA Tech Bulletin medication reconciliation Lee J et al Annals Pharmacotherapy 2010
5.Wong J et al Annals Pharmaco Stowasser, J Pharm Pract Res 2002

10. Medication reconciliation – the solution
Formalised medication reconciliation at admission, transfer and discharge reduces medication discrepancies (errors)
by 50 – 94% 1-4
Vira T, Colquhoun M,et al. Qual Saf Health Care 2006;15:122-6.
Pronovost P, Weast B, et al. J Crit Care 2003;18:201-5.
Santell JP. Jt Comm J Qual Patient Saf 2006;32:225-9.
Rozich JD, Resar RK. J Clin Outcomes Manage 2001;8:27-34
At the same time studies were showing that a formalised process of medication reconciliation reduced the risk of medication errors and adverse events at transitions of care by 50 to over 90%.

11. Medication reconciliation
“Medication reconciliation is the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care”.
The SOP defines medication reconciliation as

12. Medication reconciliation SOP
Formal, structured process
Staff trained
Multidisciplinary
Doctors, nurses, pharmacists, pharmacy technicians
Partnership with patients, families, carers
Integrated into existing processes of care
Within 24 hours of admission
Phase 1
On admission for patients ≥ 65 years of age admitted through emergency department to a hospital ward
The SOP called for a formalised structured approach to the medication reconciliation process. With staff trained in the process.
The process was to be multidisciplinary and done in partnership with patients, families and carers. Hospitals were recommended to integrate the process into their existing workflows. The medicines were to be reconciled within 24 hours of admission.
As the process was known to be challenging to implement , a phased approach was taken with Phase 1 focusing on older patients admitted via the emergency department to a hospital ward .

13. Medication reconciliation process
Step 1
Obtain a best possible medication history (BPMH)
Step 2
Confirm the accuracy of the history
Step 3
Reconcile the BPMH with prescribed medicines
Step 4
Supply accurate medicines information
There were four steps to the medication reconciliation process. Obtaining a Best Possible Medication History, verifying the accuracy of the information using one or more sources of information, reconciling the BPMH and medicines ordered and providing an accurate and complete list of medicines when handing over care. These steps aligned very closely with the APAC Guiding Principles to achieve continuity of medication management and the SHPA Standards of Practice for Clinical Pharmacy Services.

14. Interview patients and/or carers ( if possible) Systematic approach
Step 1
Obtain a best possible medication history (BPMH)
Interview patients and/or carers ( if possible)
Systematic approach
Compile an accurate and comprehensive list
Current medicines patient taking
prescription, OTC, complementary medicines
Recent changes, medicines ceased
Notes:
I will quickly go through the four steps . Firstly the BPMH. The aim of the BPMH is to determine what medicines the patient is actually taking. It includes a obtaining a history of all regular medicines used (prescribed, non-prescribed (OTC) and complementary medicine ), using a number of different sources of information, including an interview with patient and carers/families (if possible). A systematic approach is required and staff need to be trained in the technique . The concept of a BPMH acknowledges that it is not always possible to have an exact record of a patient’s medication history, but that at all times an effort should be made to construct the most accurate medication history possible given the resources available.

15. Confirm accuracy of history
Step 2
Confirm accuracy of history
Verify with one or more sources
Carer or family
Medicine containers (including blister packs)
Medicines lists (patients)
GP lists, records
Community pharmacy records
Electronic/paper health records, discharge records
Medication charts from other facilities e.g. nursing home
The history must be confirmed with at least one other source of information such as: medicine containers, patients’ medicines lists, community prescribers and/or community pharmacist (with patient consent), health records. Several sources of information may be required .

16. Document in one place in patient record
Use to :
Document BPMH
Document sources of information
Reconcile history with prescribed medicines.
Document issues, discrepancies and actions.
Notes:
The BPMH is required to be documented in one place in the patient record and available for all members of clinical team to and use as the one source of truth of the admission medication history. In Australia the Commission released the National Medication Management Plan in for hospitals to use in the project – the form was developed from the Qld Health Medication Action Plan . Hospitals were encouraged to keep the MMP with the active medication chart(s) throughout the patient’s admission. Those hospitals with existing forms for recording Medications taken prior to Presentation to Hospital and documenting the reconciliation process were allowed to continue to use their forms.
Keep with NIMC
for easy access
One source of truth

17. Step 3 Reconcile BPMH with prescribed medicines
Compare with medicines ordered
Resolve discrepancies with prescriber, document changes
In Step 3 the patient’s BPMH is compared with the medicines prescribed on the medication chart (NIMC) to Check that they match, or that any changes are clinically appropriate. Any discrepancies are discussed with the prescriber and reasons for the changes to therapy documented.

18. Medicines can be reconciled proactively - where the BPMH is completed before the medicines are ordered and used to derive the orders. This model can be used in ED departments for non urgent cases and pre-admission clinics. Alternatively medicines can be reconciled retroactively, such as for urgent admissions in EDs where a primary medication history is taken and admission orders written before the BPMH is taken. In this case the BPMH is compared with the AMOs and any discrepancies followed up with the prescriber.

19. Supply accurate medicines information
Step 4
Supply accurate medicines information
The person taking over the patient’s care is supplied with an accurate and complete (reconciled) list of the patient’s medicines and explanation of any changes.
Internal transfer of care (e.g ICU transfers)
Discharge
Care provider
Patient and carer
Notes:
The final step is the process whereby the person taking over the patient’s care receives an accurate and complete list of the patient’s medicines, whenever the patient’s care is transferred. For example between wards or facilities and at discharge. With the patient (or carer) receiving the list on discharge.
On discharge, the medicines ordered need to be reconciled against the current orders on the NIMC AND the BPMH on the MMP. The system must ensure the discharge summary is updated with any changes and the reconciled list used to produce the patient medication list.

20. Project methodology Complete AHRQ patient safety culture survey
Implement Medication Reconciliation SOP
Using QI methodology
Evaluation plan
Implementation experience survey (6 monthly)
Performance measures
Rate and quality of medication reconciliation
Analysis of SOP related adverse events
In-depth interviews with 3 sites
5 sites in Australia
All hospitals were required to complete the US Agency for Healthcare Research and Quality patient safety culture survey prior to implementing the SOP. QI methodology was used to implement the SOP and implementation was evaluated using a multipronged strategy. This involved the collection of hospital experience data, measurement of performance and the analysis of SOP related adverse events to determine any unintended consequences associated with the SOP.
Helen will discuss the evaluation component in more detail.
During the project it was decided that it was important to determine the context in which the project was implemented in each country to see if this influenced the implementation in the different countries.

21. Project implementation in Australia
Commenced January health services
2 x 2 day workshops 2010
2 x 1 day workshops in 2011
Video conference 2013
Teleconferences - monthly then 2nd monthly
Webinars, newsletter
All materials posted on High 5s website
Support from senior project officer
The project commenced in Australia in January 2010 when the first of the monthly teleconferences was held with all sites with around 60 people attending.
The first workshop was held in April in Sydney 2010 where teams were introduced to the medication reconciliation SOP and received training in implementation planning as well as Failure Mode Effect Analysis. Teams went away with a daft plan for their site.
Subsequent workshops, video conferences and webinars provided the opportunity for sharing progress with implementing the SOP and discussing the evaluation strategy – especially the performance measures.
Other strategies to maintain momentum during the 5 years of the project were regular teleconferences, webinars on specific topics, and an newsletter.
All workshop and webinar presentations were posted on the High 5s website.. 21 21

22. High 5s workshop 2011 Poster award winners High 5s hospitals workshop
Peoples choice
All participating sites welcomed the opportunity to met and work with the other hospitals. These are some happy participants from the 2011 workshop.
Poster award winners
High 5s hospitals
workshop

23. Implementation resources
Hospitals had access to a number of resources including the SOP and Getting Started Kit or implementation guide..

24. There was the Wiki website that provided all project materials and other shared resources. Each country had its own webpage for posting materials. Hospitals were able to run reports on their measurement data.

25. Medication reconciliation resources
MATCH UP Medicines Resources
The Commission worked with the Australian sites to develop a series of resources for hospitals to use to help implement medication reconciliation.
These include the national medication management plan for recording the BPMH and reconciling prescribed medicines, an accompanying user guide, a poster and a streamed presentation on how to use the MMP. A range of education resources were also developed using the MATCH UP Medicines tag line and included: a brochure for health professionals and a poster. These resources and all the other resources developed for the project are available from the Commissions website.
Medication management plan
+ implementation resources 25 25

26. Medication reconciliation resources
“Get it right. Taking a best possible medication history ”
Video
CD and You tube channel
www. Safteyandquality.gov.au
Online learning module
At the request of the sites a video and more recently an online learning module was developed in cooperation with NPS MedicineWise for health services and universities to use to train staff and students to take a BPMH

27. Improving quality and timeliness of information on admission
Engaging with consumers
“Mistakes can happen with your medicines”
How to prevent them
Have a medicines list
AUSTRALIA: Australian Commission on Safety and Quality in Healthcare
Bring medicines with patient
To improve the quality and timeliness of information on admission the Commission engaged with the Council of Ambulance Authorities Inc to encourage ambulance officers to bring patients’ medicines into hospital when patients were admitted from home.
Encouraging patients to maintain a current list of medicines was also seen as an important piece of the jigsaw in improving communication about medicines and the Commission and NPS MedicineWise jointly developed a wallet and an A4 flyer for hospitals to distribute at time of discharge, informing patients of the importance of keeping a current list of medicines and showing it to their health care provider.
Patient’s medicines lists 27

28. Implementation Strategy
Oversight of implementation
Project work plan
Risk assessment of proposed process
Pilot testing
Spread methodology
Communication plan
Evaluation Strategy
Maintenance and improvement
Health Services were required to implement the medication reconciliation SOP using standard quality improvement methodology. This included:
Securing senior leadership commitment and forming a multidisciplinary project team;
Developing a project work plan and undertaking a risk assessment of the proposed process.
Pilot testing the process before spreading it throughout the health service.
Measuring process improvement, communicating feedback to staff and management and developing a communication plan for raising awareness of the project within the organisation.
Details on the implementation strategy are available in the SOP and implementation guide.

29. Reasons for withdrawal
6 Australian health services withdrew Change in priorities 2 Lack of resources for evaluation, independent observer 2 Lack of resources for MR process , evaluation 1 Concern re MR taking focus away from medication review 1 Lack of perceived benefit 1
Six health services withdrew from the project. Reasons included lack of resources for the MR process itself and/or the evaluation component, change in priorities of new pharmacy managers, concern that MR was taking focus away from medication review.

30. Lessons (International)
Full implementation was challenging
Reliant on pharmacists for success
Additional pharmacists needed for:
More timely BPMH, medication reconciliation
Coverage for after hours, weekends and holidays
Coverage of new areas , wards units
Performance measurement essential
International lessons.
Confirmed that full implementation was challenging
It was most successful when Pharmacists (or pharmacy staff) were performed medication reconciliation.
Many sites identified the need for additional pharmacists for: more timely medication reconciliation, Coverage for after hours, weekends and holidays and extending the process to new areas , wards/units.
Data measurement and feedback were considered essential – they demonstrated a need for the SOP, provided a tool for demonstrating the impact of implementation efforts, and helped maintain attention on the patient safety issue.

31. Lessons – Challenges and barriers
Barriers and challenges to SOP implementation
Lack of resources
- Training materials, medication reconciliation form
Lack of human resources for:
Med Recon
Data collection
Ongoing training
Competing priorities
Considered “Pharmacy Business”
Lack of buy in by:
Organisational leadership
Senior staff
Lack of Technology to support Med Recon
Key challenges and barriers to implementation were common across the countries such as: lack of resources, competing priorities, resistance to change and lack of buy in. MR was considered very much a pharmacists role. Helen and other speakers will discuss these issues in greater detail.

32. Lessons – Benefits of SOP
Reported benefits of the SOP
Positive impact on:
Related activities
Patient care
Reduced medication discrepancies and potential ADEs
Measurement data used for business case to gain additional pharmacist resources
Improved communication between hospitals and community care providers
Improved multidisciplinary
teamwork
Improved documentaton
Hospitals reported that SOP implementation reduced medication discrepancies and potential adverse drug events, led to improvements in related medication management activities and re-enforced a culture of medication safety. It encouraged multidisciplinary teamwork and there was a greater awareness of errors on admission as a med safety issue. A standardised MR process was considered to have had a positive impact on patient care.

33. Drivers for SOP implementation
National guidelines and standards
Accreditation requirements
Access to community dispensing data
Pharmacy technicians
Countries with mandatory guidelines or standards and/or accreditation goals requiring medication reconciliation within 24 hours of admission had greater success.
Hospitals having direct access to community dispensing data were able to expedite the preparation of the BPMH.
Some countries were successful in using pharmacy technicians to obtain the BPMH.

34. What makes for effective and sustainable medication reconciliation?
Recognition as a patient safety priority
Senior leadership support from the health service executive and senior clinicians
Interested and influential clinical champion(s)
Resources to conduct medication reconciliation and measure improvement
Effective and sustainable Med Rec requires:
Recognition that medication reconciliation is a patient safety priority
It needs senior leadership support from the health service executive and senior clinicians s well as interested and influential clinical champion(s)
Resources are needed to conduct medication reconciliation and measure improvement

35. Effective and sustainable medication reconciliation (cont’d)
Ongoing training of clinical staff
Policies and procedures on medication reconciliation
Integration of Med Rec into existing work flows, electronic health records and clinical information systems.
Ongoing training of clinical staff is important to achieve and sustain compliance with the SOP. All staff with responsibilities for taking medication histories (including the primary medication history) should be trained in how to take a best possible medication history (BPMH) – not just pharmacists.
Policies and procedures on medication reconciliation are required and staff need to be aware of their responsibilities.
The process needs to be integrated into existing work flows, electronic health records and clinical information systems. Hospitals integrating MR into workflows performed significantly better in terms of the performance measures. This afternoon we will hear more about integrating MR into e-system.

36. Further information on High 5s project
Further information about the project can be obtained from the WHO High 5s Project Interim report available from WHO website and the Australian Interim report on the Commission’s website.

37. NSQHS Standard 4 – Medication safety
So how does this work relate to the Medication safety standard.

38. Medication Safety Standard
Implementing the Med Recon SOP will assist health services achieve several action items in the Medication Safety Standard, including the criterion on documenting patient information.

39. High 5s Project Resources
The Med Recon SOP and implementation guide will assist hospital implement an effective Med Recon process and the measures have already been used by High 5s hospitals as evidence for meeting the standard.

40. Medication safety standard
Implementing Med Recon at discharge will assist hospitals to achieve the continuity of medication management criterion.

41. Indicators 5.8 and 5.9 in the new National QUM Indicators for Australian Hospitals will assist hospitals meet the continuity of medication management criterion. implement Med Recon on discharge. These indicators were developed with input from the Australian High 5s hospitals as tools for hospitals to use to measure improvements in the quality of medicines information in discharge summaries patients’ medication lists and provide evidence for Actions items 4.11 in the Medication Safety Standard.

42. Australian Project Results
Margaret Duguid
Pharmaceutical Advisor
Helen Stark
Senior Project Officer

43. Importance of measurement Evaluation Strategy Evaluation Results Resources

44. The Problem
Tam VC, Knowles SR, Cornish PL et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ, 2005; 173:

45. The Problem Recent Australian paper1
Multi-centre, prospective observational study in 8 EDs
Patients taking more than one medicine and a GP referral letter (median 6)
GP referral letters compared with BPMH taken by ED pharmacist n=414 patients
1. Taylor S et al, Australian Family Physician Vol. 43, No. 10 Oct 2014

46. The Problem
87.2% patients had one or more discrepancies between BPMH and GP referral letter Median no. of discrepancies was 3 Most common: omission of regular medicine or inclusion of a medicine patient no longer taking 62.1% of patients had one or more discrepancies of moderate or high significance

47. Multi-component evaluation strategy
Measurement an integral component of the SOP
Performance measures
SOP implementation experience
Event Analysis

48. 1. Performance Measures Four years of data (June 2010 to June 2014)
Four measures (MR1 – 4)
10 hospitals contributing, staggered implementation
Project level – results show significant variation from hospital to hospital and country to country
Present Australian data only

49. MR1: Percent of patients reconciled within 24 hours of decision to admit
Purpose:
Measure hospital’s capacity to reach as many eligible patients as possible
Creation of BPMH, identification of discrepancies & communication to prescriber within 24 hours
Method:
Eligible patients: 65 years and over admitted through ED to inpatient services
All eligible patients or random sample of 50 using approved sampling method
Monthly data collection
Entry into High 5s secure website, approved by Commission
Goal: 100%

50. MR1: Percent of patients reconciled within 24 hours of decision to admit
MR1 ranged from 41.8% to 59.4% across participating hospitals with an average of around 50.4%
Trend line stable
Key finding: Reconciliation within 24 hours regarded as ideal for patient safety but difficult to achieve for majority of hospitals

51. MR1: Percent of patients reconciled within 24 hours of admission

52. Quality measures: MR 2,3,4 Purpose: Method: Goal:
To verify quality of medication reconciliation process
Use independent observer to pick up outstanding medication discrepancies
Intentional vs unintentional, documented vs undocumented
Method:
Chart audit (n=30) from sample of 50 taken for MR1
Prospective or retrospective
Monthly then quarterly or six monthly if stable
Data verification & entry into High 5s website
Goal:
Aim to reduce to a minimum
MR3 target of less than 0.3 per patient
MR4 no target specified

53. Quality measures: MR 2,3,4 Measure Description
Description
MR-2
Mean number of outstanding undocumented intentional medication discrepancies per patient
MR-3
Mean number of outstanding unintentional medication discrepancies per patient
MR-4
Percentage of patients with at least one outstanding unintentional discrepancy
Measuring accuracy of the medication reconciliation process
Discrepancies that have “slipped through the cracks”
MR2 example: betablocker stopped by surgeon before surgery but not documented anywhere
MR3 example: omission, commission, wrong medication, strength, dose or form

54. MR2 – mean undocumented intentional discrepancies per patient
Prescriber made an intentional choice to add, change or discontinue a medication but decision not clearly documented Creates confusion, additional work and could lead to ADEs

55. MR3 – mean outstanding unintentional discrepancies per patient
Where med rec is conducted, hospitals achieved target of less than of 0.3 outstanding unintentional medication discrepancies per patient, with trend towards zero over time for several hospitals

56. MR4 – percent of patients with at least one outstanding unintentional discrepancy

57. Limitations of MR1 - 4 Small sample size for MR 2 – 4
Only review med recs done within 24 hours
Definitional issues
what to include as a discrepancy/MR2 vs MR3
Inter-rater reliability issues
Prospective vs retrospective data collection
Herbal medicines should be documented on BPMH however omission considered to be intentional and discrepancy not counted eg., MO didn’t order Ginseng but not documented
OTC medicines should be treated same as prescription meds because prescriber needs to make decision about continuation or non continuation eg aspirin

58. 2. Implementation Experience Surveys
All hospitals completed survey every 6 months
Annual interviews conducted in 5 hospitals
Provided additional insight on hospitals’ experience

59. Reported benefits from SOP
Reduction in medication discrepancies and potential medication errors Standardisation of med rec processes across the hospital Spreading from admission to discharge and improved business processes at discharge Embedding process into hospital work flow and routine data collections - strong framework for hospitals to meet relevant criteria in the Medication Safety Standard 4
All hospitals had spread the SOP beyond patients admitted through the ED but to varying degrees
A small number of the hospitals target all patients however the majority prioritise hospital-defined “high risk” patients

60. Reported benefits from SOP
Improved teamwork & recognition of importance of med rec among non-pharmacist clinicians and senior mgt Improved communication with community health care providers and patients Opportunity to participate in international patient safety project and associated benefits of sharing lessons learned nationally and internationally Access to Commission training materials and resources Using High 5s data to obtain additional pharmacy staff for medication reconciliation after hours/weekends

61. Reported benefits from SOP
Multi-facetted High 5s evaluation strategy provided hospitals with in-depth understanding of the medication reconciliation service
Performance measures useful for:
Tracking improvement, providing feedback to staff, mgt
Identifying gaps in practice, training requirements
Developing business case for resources
MR 1 and MR3 - most useful
Majority will continue to evaluate med rec with some moving focus to discharge
Med rec now part of “usual care”

62. “The High 5s project has engendered pharmacists and medical staff with a greater understanding of the value of preventing adverse consequences from medication discrepancies and clear documentation of their intentions. Although we believed that we already performed medication reconciliation to a high standard, the audit process has allowed us to become more consistent across our service” (metropolitan hospital)

63. Challenges – staff resources /staff resistance
No. patients receiving medication reconciliation is closely tied to available clinical pharmacist resources Medical and nursing staff often report “not their job” Some nursing staff feel they lack the necessary pharmaceutical knowledge to perform this task Hospitals report some improvement in teamwork over project Real change requires education at under graduate level
Not my job!

64. Challenges – lack of staff
No. of clinical pharmacists varies markedly by hospital and sector
Private hospitals - less clinical pharmacists resulting in lower rates and reduced ability to spread med rec across the organisation
Education of large numbers of staff – required significant initial and ongoing commitment & resourcing (under estimated upfront)
Hospitals were required to re-allocate clinical pharmacy staff from other tasks to conduct med rec and/or for project evaluation and education

65. How many hours per week does the hospital provide a medication reconciliation service?

66. Challenges – lack of electronic systems
Lack of integration of med rec (paper) with eMM systems
Some sites had a new eMM system in ED introd. during project
“Medication reconciliation is conducted in all inpatient areas. Improving timely rates of medication reconciliation on all eligible patients within 24 hours will only be possible when electronic documentation of medication reconciliation is available and this tool can interact with current medicine management systems”.
(large metropolitan teaching hospital)

67. Future Plans
Plans to implement electronic systems for medication reconciliation

68. 3. Event Analysis (EAs) 3rd evaluation component
Hospitals required to actively seek and investigate events that should have been prevented by the SOP
EA – systematic analysis of the facts & contributing factors leading to an patient safety incident (“mini RCA”)
Link to SOP implementation

69. Event Analysis (EAs) 17 EAs reported by 6 hospitals
No serious ADEs reported over the course of the project
Most events due to a failure to undertake med rec in timely fashion
Major contrib. factors were lack of teamwork, education & training and poor communication
Those that did EA learnt from analysis of actual ADEs
Case studies used for education of other clinicians
Improved processes
Business case for more resources

70. EA Case Study
A 73 year old Parkinson’s patient was admitted for investigation and rehabilitation after a fall
The patient had his Webster pack with him which had clear dose times and directions to give Parkinson’s medicines at 6am, 10am, 2pm, 6pm and 10pm however the MO ordered medicines for the first four dose times only omitting all the 10pm doses
The omitted medicines included: levodopa/carbidopa CR200/50mg, mirtazapine 30mg, pregabalin 25mg and quetiapine 50mg
There was no clinical pharmacist on the ward because the usual pharmacist was on leave with no replacement cover

71. EA Case Study
The patient was not given doses of his usual 10pm medications for the next two days
It was recorded throughout the patient’s notes that the patient was having multiple mobility issues. The nurse recorded that this could have been part of his usual symptoms or alternatively, a worsening of his Parkinson’s symptoms i.e. “Parkinson’s tremor gradually worsening throughout shift”

72. EA Case Study
The treating MO asked a clinical pharmacist on a different ward to see the patient on the third day because of worsening mobility
The pharmacist interviewed the patient but he was a poor historian and was unable to give an accurate medication history
The pharmacist then spoke to the patient’s wife (carer) to establish the correct medicines as well as using the Webster Pack brought into the hospital as the 2nd source for the BPMH
After seeing the patient and taking the BPMH the medication errors were noted and the Doctor was asked to amend the medication orders
The doctor re-charted all of the omitted medicines. The patient’s symptoms gradually abated and he recovered fully the next day

73. Learning from EA
The process of taking a BPMH and admission reconciliation was introduced to JMOs at orientation
The hospital used case study to educate JMOs on importance of using multiple sources to confirm the medication history, including blister packs
Business case for additional clinical pharmacist
“…Involving the medical and nursing staff as well as the Quality Manager in the event analysis process has resulted in new policies and actions to prevent near misses. The teamwork involved in the project has resulted in greater cooperation between clinicians which in turn has led to less medication errors (eg omission errors)….”
(metropolitan hospital)

74. Commission Resources
SOP & Implementation Guide MMP, user guide and flash presentation MATCH Up medicines brochures & posters BPMH Video and online learning module Consumer wallet
There are several resources available to assist health services implement medication reconciliation. All Australian materials developed for the High 5s project and links to overseas materials can be accessed from the medication reconciliation page on the Commission’s website.

75. Conclusion Now let’s hear from the hospitals
Feasible to implement High 5s Medication Reconciliation SOP in different countries and cultures
Requires some local and national adaptation
Improves patient safety
Complex process
Challenging to implement, requires careful planning
Measurement is critical to successful implementation
Now let’s hear from the hospitals
Feasible to implement High 5s Medication Reconciliation SOP in different countries and cultures
Requires some local and national adaption
The process can improves patient safety. Helen will talk more about this.
It is a complex process involving a number of different professional groups and patients and carers and is challenging to implement.

76. Acknowledgements High 5s hospitals
Alfred Health Vic
Armadale Health Service WA
Epworth Healthcare Richmond Vic
Greater Southern AHS NSW
Logan Hospital, Qld
Mater Health Services Qld
Noosa Hospital Qld
Medication Continuity Expert Advisory Group
North West Regional Hospital TAS
Prince of Wales Hospital NSW
Redland Hospital NSW
Rockingham Hospital WA
Royal North Shore Hospital NSW
The Wesley Hospital Qld

77. Australian Commission on Safety and Quality in Health Care E: