1. Implementing Medication Reconciliation in Long-Term Care O’Connell
Date: April 14, 2008
by Bonnie Walker
Risk Manager /Patient Safety Advisor
Chris

2. Safer Health Care Now! National Canadian Patient Safety Campaign!
National Steering Committee - Canadian Patient Safety Institute (CPSI)
Purpose:to help teams,hospitals develop skills/capacity to make quality improvements and monitor their performance
Provide ideas, supports and resources to hospital teams across the country with the goal of providing safer care.
Focus is harm reduction and improving care processes and outcomes for patients, families and caregivers

3. Canadian Adverse Events Study
7.5% of all hospital admissions are associated with an adverse event (2000)
36.9% of which were deemed preventable
Translates to 70,000 preventable adverse events per year
Contributing to between 9,000 and 24,000 preventable deaths in Canada (2000)
Adverse Events in Canadian Hospitals (Baker, R. & Norton, P. et al (2004))

4. The Evidence
Many patients (37% on average) had drug omissions at admission.
Cohen J, Wilson C, Ward F. Pharmacy in Practice 1998;13-6.
Many patients (70%) not receiving medication instructions at discharge.
Alibhal SMH, Han RK, Naglie G. J Gen Intern Med 1999;14:
Medication histories are often incorrect or complete:
- 25% of Rx. Medications not listed
- 61% of patients have 1+ med not listed
Lau HS et al. Br J Clin Pharmacol 2000; 49:

5. The Evidence
Chart reviews have revealed that over half of all hospital medication errors occur at the interfaces of care
Rozich et al., J. Clin Outcomes Manage. 2001; 8(10):27-34)
J Clin Outcomes Manage 2001;8:27-34
Implementation of medication reconciliation along with other interventions decreased the rate of medication errors by 70% and adverse drug events by 15%, over a seven month period.
Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care 2004;13(1):53-59

6. The Evidence
A successful medication reconciling process reduces work and rework
- reduced nursing time at admission by over 20 minutes per patient
- reduced pharmacists time at discharge by over 40 minutes
Rozich,JD, Howard RJ,Justeson JM, Macken PD, Lindsay ME,Resar RK. J Quality Saf. 2004: 30(1):5-14

7. SHN Improvement Initiatives:
Medication Reconciliation
Acute Myocardial Infarction (AMI)
Surgical Site Infection (SSI)
Rapid Response (RRT)
Central Line Infection
Ventilator Associated Pneumonia (VAP)
Falls LTC
MRSA
DVT

8. Medication Reconciliation
As of March 2008:
240 healthcare organizations and 885
teams enrolled nationwide (325 Med Rec Teams)
26 districts / organizations enrolled from Atlantic Canada

9. Medication Reconciliation
Goals:
The primary goal of medication reconciliation in long-term care is to eliminate undocumented intentional discrepancies (documentation errors) and unintentional discrepancies (medication errors:omissions, additions etc.) by reconciling all medications, at all interfaces of care, for all residents.
Improve the process of obtaining, updating and communicating a complete Best Possible Medication History (BPMH)
The primary emphasis is to create systems of care that dramatically reduce the number of Adverse Drug Events through the reconciliation of medications.
Chris

10. Medication Reconciliation Measures of Success
# of undocumented intentional discrepancies (documentation accuracy).
# of unintentional discrepancies (medication error).
% of residents that are reconciled.
Chris

11. What is Medication Reconciliation?
A process in which medications are compared at interfaces of care:
Admission
Transfer
Discharge
Discrepancies are identified and reconciled with physician
Intervention minimizes patient harm from unintended discrepancies
ISMP Canada 2005

12. What is Medication Reconciliation?
“a formal process of obtaining a complete and accurate list of each patient’s current home medications-including name, dosage, frequency and route- and comparing the physician’s admission, transfer, and/or discharge orders to that list. Discrepancies are brought to the attention of the prescriber and, if appropriate, changes are made to the orders. Any resulting changes are documented.”
ISMP Canada 2005

13. (Best Possible Medication History)
What’s a BPMH?
(Best Possible Medication History)
Documentation of all medications that a resident has been taking previously including drug name, dose, frequency and route.
Chris

14. Review medication lists, MARs, vials Interview resident and /or family
Obtaining BPMH
Community pharmacy
Review medication lists, MARs, vials
Interview resident and /or family
Consult notes from referring physician
H&P
Tanis

15. Nursing/pharmacist (referral) to collect information at admission
Obtaining BPMH
Nursing/pharmacist (referral) to collect information at admission
Physician-as a reference and/or order when writing initial orders for medications
Physicians/nurses/pharmacists throughout the resident’s stay as a reference
Tanis

16. Virtually all hospitals who have successfully addressed admission medication reconciliation have created a special form as part of the solution!

17. Completing the Medication History / Admission Orders form!

18. Include all sources required to thoroughly complete the BPMH.
Include history of illnesses.
Note height and weight and known allergies.

19. Continue to Complete by:
List name, dose, route, frequency for each medication.
Signature,date and time when BPMH is completed. To be done within 24 hrs.
Obtain physicians intention to continue, change, discontinue or hold. Obtain reason.

20. Continue to Complete by:
Obtain physician admission orders for pre admission medications.
Indicate risk score for pharmacy referral.
Indicate disposition of residents medications.

21. Continue to Complete by:
Note additional pre-admission medications identified after 24 hrs here.
Sign, date and time additional medications noted.
Ensure orders for additional medications are noted on routine Physician Order pink sheet.

22. Complete Risk Score: Score all categories and add final risk score.
Fax all completed risk scores to Pharmacy!

23. Medication History Taking
Include:
Current home medications including dose,route and frequency
Medications ordered at admission
Continue,start, stop
Time of last dose
Source of the information
Assessment of patient compliance
OTC’S and herbals (organization decision)
Tanis

24. Medication History Taking
Interview:
Encourage questions from the resident / patient
Encourage bringing medications and use of medication wallet card or home list
Prompt regarding non-pill dosage forms and PRNs
Creams, drops, inhalers, spray, samples
Tanis

25. Medication History Taking
Interview:
Balance open-ended questions with yes/no questions
Nonbiased questions
No leading questions
Vague responses may indicated non-adherence
Avoid medical jargon
Tanis
Make sure everyone is on the same page - often different disciplines have different perspectives or are unaware of steps outside their area of work
2. Uncover potential problems, bottlenecks, unnecessary steps & rework loops in the process
3.Guide discussion on Iding problems, potential solutions and holding the gains without having to physically observe the process

26. Medication History Taking
Interview Questions:
Do you have any allergies to medication? Describe the reaction.
What medication were you taking prior to admission?
Did a doctor change the dose or stop any of your medication recently?
Have you changed the dose or stopped any of your medication recently?
Have you recently started any medications?
Tanis
Forces team members to narrow their thinking to only those essential steps in the process
2. Resulting picture represents only useful work, omitting inspection, rework and other steps that have evolved to detect or respond to quality problems.
3. Useful because helps to “weed out” those steps which did not add value
4. Don’t get lost in the process
5. Can be used as an outline for a project or pathway solution being developed

27. Medication History Taking
Interview Questions:
Have any of your medications been causing side effects?
When you feel better, do you sometimes stop taking your medication?
Sometimes if you feel worse when you take your medication, do you stop taking it?
Are the pills in the bottle the same as what is on the label?
Have you changed your daily routine to accommodate your medication schedule?

28. Tanis
Source: SHN Medication Reconciliation Getting Started Kit (2007)

29. Why Medication Reconciliation?
Medication reconciliation fits with culture of safety and optimal patient / resident care
Medication reconciliation evidence has shown reduced medication discrepancies
Medication reconciliation will save time for nurses, physicians, and pharmacists
Already take a medication history: now we are doing it on one form and it will be easier to find
Tanis

30. Why Medication Reconciliation?
Will know that a medication change is intentional (rather than wonder if there was a transcription error or a missed order), and be able to advise the patient / resident and family members accordingly
It will be easy to find the at-home medication list in order to reconcile on transfer / discharge as all preadmission medications will be on the new admission form
Outcomes from the changes with medication reconciliation are being monitored for improvements
Chris

31. Questions
Chris