1. …a shared responsibility for health care Medication Reconciliation A Saskatoon Health Region Initiative

2. Medication Reconciliation – what is it? A formal process of: –Obtaining a complete and accurate list of each patient’s current home medications (name, dosage, frequency, route) –Comparing the physician’s admission, transfer, and/or discharge orders to that list –Bringing discrepancies to the attention of the prescriber and ensuring changes are made to the orders, when appropriate Reference: IHI, Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation)

3. Medication Reconciliation can: Prevent omission of an at-home medication Match in-house dose, frequency and route with at-home dose Assure medications follow the patient from one care site to another

4. Why? Recent media attention and legal cases Concern over patient safety is growing, both among the Canadian public and among health care providers 2.9-16.6% of patients in acute care hospitals experienced one or more adverse events Greater than 50% of all hospital medication errors occur at the interfaces of care –Admission to hospital, Transfer from one nursing unit to another, Transfer to step-down care, Discharge from hospital

5. Why Now? It’s the right thing to do…….. –Culture of safety: reduce medication errors & potential for patient harm –Key component of seamless care strategies –Saves time for physicians, nurses, and pharmacists in the long-term Medication Reconciliation is a new Canadian Council on Health Services Accreditation Standard Senior Leadership has endorsed Medication Reconciliation as a Regional Project of high priority

6. Potential Impact 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.[i] Implementation in a surgical population reduced potential adverse drug events by 80% within three months of implementation.[ii] [i] Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care 2004;13(1):53-59 [ii] Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm 2003;60:1982-1986

7. Potential Impact There was a five fold reduction (1.75% to 0.35%) in the number of medication errors upon admission with implementation of medication reconciliation upon admission.[i] For those with no missing medications, drug related problems after discharge were reduced from 85% with original prescription process, to 35%.[ii] [i] Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. J Qual Patient Saf 2005;31(7):406-413 [ii] Poole DL, Chainakul MP, Graham L. Medication reconciliation: A hospital necessity in promoting a safe hospital discharge. J Healthc Qual (NAHQ) 2006 May/June

8. Potential Impact: The Time Crunch!! Nursing Time at admission was reduced by 20 minutes per client, and pharmacist time at discharge was reduced by over 40 minutes per client.[i] [i] Rozich JD, Resar RK, et al. Standardization as a mechanism to improve safety in healthcare: impact of sliding scale insulin protocol and reconciliation of medications initiatives. Jt Comm J Qual Patient Saf 2004;30(1):5-14

9. Origins of Medication Reconciliation The Institute for Healthcare Improvement (IHI) introduced the 100K Lives campaign in December 2004 to challenge health care providers to join a national effort to make health care safer & more effective & ensure hospitals achieve the best possible outcomes for all patients On April 12, 2005, the Canadian campaign, Safer Healthcare Now! was created. SHR is a registered member.

10. SHR Medication Reconciliation Initiative Ultimate goal: –Prevent adverse drug events by implementing medication reconciliation How? Use the Model for Improvement –Use Plan, Do, Study, Act (PDSA) cycles to test form and process –Make small changes, test, obtain feedback, revise and re- test. Start with the Admission process

11. Pilot Sites & Champions RUH Pediatrics RUH Surgery 5000 SPH 6 th Medicine SCH Gynecology 4300 (PAC) St. Elizabeth’s Hospital (Humboldt)

12. Stories

13. SHR Baseline Data Undocumented Intentional Discrepancies: –1.32 / patient Unintentional Discrepancies: –1.28 / patient Medication Reconciliation Success Index: –67.9%

14. SHR Form and Process A formal process of: –Obtaining a complete and accurate list of each patient’s current home medications (name, dosage, frequency, route) –Using the information obtained to write the admission orders –Referring back to the information obtained to write transfer and discharge orders

15. Medication Reconciliation Form and Process

16. 1. Addressograph 2. Allergies ISMP standard. Required information for pharmacist to process order. 3. Height & Weight ISMP standard

17. 4. List all medications patient was taking PTA, including name, dose, frequency, route. [MD, RN/LPN/RPN, BSP] Do not re-write meds on admitting databases [use stamp]. 5. Time / date of last dose.

18. 7. MD to indicate if med is to continue, stop, or change. Comments can also be added. 6. Name of person who obtained history. 8. MD signs / dates order. Once this occurs no further changes can be made to order section. RN crosses out blank lines.

19. 10. A form is completed for all patients even if on no medications prior to admission. 9. RN/LPN/RPN initials when orders are processed, faxed, and MAR’d. 11. Document any comments, concerns, or follow- up required.

20. Other: If PAC patient: double check info on day of surgery. Source of information. Disposition of patient’s medications. Check if information continues on second page. Page number

21. Page 2 available, when necessary

22. Take new form & check ‘addendum’ if additional information becomes available after the original form has been signed by the physician. Document the changes only. Patient / caregiver, etc. provide new information at later date.

23. Stamp

24. Complete & Accurate Medication List Essential component of safe and effective patient care. Essential component of medication reconciliation. List should include information on all medications the patient was taking prior to admission, including prescription, non-prescription, herbal products, and supplements.

25. Questions to Obtain Admission Medication List 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?

26. Questions to Obtain Admission Medication List 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?

27. Vision for the Future Admission Form linked to Drug Plan Information IT solutions - Transfer and Discharge piece Working on various strategies to make the process safer and simpler

28. DRAFT

29. The Train Has Left The Station...Are YOU On It? Medication reconciliation fits perfectly with SHR’s culture of safety and optimal patient care Medication reconciliation has already shown reduced medication discrepancies on pilot sites within SHR

30. Results: Run Charts of Key Measures Baseline PDSA #2 PDSA #3

31. Results: Run Charts of Key Measures Baseline PDSA #2 PDSA #3 Improving! Provide enhancements to facilitate medication history.

32. Results: Run Charts of Key Measures Baseline PDSA #2 PDSA #3

33. The Train Has Left The Station...Are YOU On It? Medication reconciliation will save time for nurses, physicians, and pharmacists HCPs already take a medication history: now we are doing it on one form and it will be easier to find Future computerization will simplify the process even more (e.g. drug plan histories will appear on the admission form)

34. HCPs 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 and family members accordingly It will be easy to find the at-home medication list in order to reconcile on discharge as all preadmission medications will be on the new admission form The Train Has Left The Station...Are YOU On It?

35. Transcription errors will be eliminated on transfer and discharge using current computer capabilities A clear discharge medication list will be available for patients, pharmacists and physicians Outcomes from the changes are being monitored (PDSA cycles), and improvements are already evident The Train Has Left The Station...Are YOU On It?

36. Questions?