1. Building Bridges in Medication Management Kerry Fitzsimons Dr Ian Craib Shelley Wood Clinical A/Prof Peter Kendall Jodie McNamara Richard Wojnar-Horton Fremantle Hospital & Health Service Western Australia.

2. Medication Errors can occur when Determining the medication the patient is currently taking, Transcribing details to the medication chart, Prescribing medications for the patient during the admission, and Communicating changes at discharge to community practitionersCommunicating changes at discharge to community practitioners. Kerry Fitzsimons 2010

3. Why Change Our Pharmacy Service ? High discrepancy rates between electronic discharge summary (EDS) and discharge medications. Team pharmacist to be more involved in discharge process. Team pharmacist to input medication information into discharge summary. Kerry Fitzsimons 2010

4. SQuIRe Medication Reconciliation Project Safety and Quality Investments for Reform (Office of Safety and Quality Dept Health WA) Kerry Fitzsimons 2010

5. Aim : To evaluate an extended clinical pharmacy service involving: Medication reconciliation on admission, Medication reconciliation at discharge (EDS), Facilitating seamless transfer of medication information to GP. To gauge whether provision of a medication profile to patients was beneficial. Kerry Fitzsimons 2010

6. Initial goals To achieve: 100% compliance of Medication Reconciliation Process 100% satisfaction with service from Medical Team patient and GPs To assess impact on workload of service and ascertain feasibility of extension of project. Kerry Fitzsimons 2010

7. Method: Clinical pharmacist assigned to a designated medical team: Obtain accurate medication history Document current medications on front of chart Reconciliation of medications with medical staff Input medication information into the D/C summary Provide medication information to patient including: MedProf © to patients discharged home Medication list to patients discharged back to N/H or hostels Kerry Fitzsimons 2010

8. Method: Data Collection Audit Tool Designed Baseline data collected Data collected at monthly intervals (n=30) Assessment using an audit tool Active arm (1 year) Control arm (4 months) Roll-out and continuous quarterly reporting Outcome Measures Medication discrepancy rates on admission and at discharge. Satisfaction survey to GPs and patients. Kerry Fitzsimons 2010

9. Results: 1. Kerry Fitzsimons 2010

10. Results: 1. Kerry Fitzsimons 2010

11. Results: 2. Kerry Fitzsimons 2010

12. Results: Kerry Fitzsimons 2010 2.

13. Results: 3. Kerry Fitzsimons 2010

14. Results: Kerry Fitzsimons 2010 3.

15. Results:

16. 4a. Kerry Fitzsimons 2010

17. Results: Kerry Fitzsimons 2010 4a.

18. Results: 4b. Kerry Fitzsimons 2010

19. Results: Kerry Fitzsimons 2010 4b.

20. Patient Satisfaction Questionnaire Feedback from patients (n=43) 79% very satisfied with discharge medication list and found it helpful, 58% had shown their GP, only 14% reporting problems with taking their medication. Kerry Fitzsimons 2010

21. GP Satisfaction Letter to Fremantle Division GPs to outline project. Poor response – All were satisfied or very satisfied Comments include: “All patients should receive this service” Letters supporting the project from GP Aged Care representative and Fremantle GP Network Kerry Fitzsimons 2010

22. Medical Staff Satisfaction Consultants to interns – all very happy to support continuation of service No official survey - feedback very positive Interns – “makes my job much easier” Improved clinician awareness of medication histories medication discrepancies the need for accurate communication at discharge. Kerry Fitzsimons 2010

23. Future of Project Funding for service. Roll-outRoll-out project to other medical teams initially and then to other specialities. Highlight need for reduced Pharmacist : Patient ratios Pharmacist : Patient ratios (1:30) to meet all requirements of Pharmaceutical Review Process Kerry Fitzsimons 2008

25. Conclusion An extended clinical pharmacy service with adequate staffing ratios (1:30) improved: The medication reconciliation process, The accuracy of the medication information communicated to GPs. Empowered patient by providing a medication list at discharge, and Support for continuation of service from GPs, medical staff and patients. Kerry Fitzsimons 2010

26. Bridging the Divide Narrowing the community – hospital divide. Enhanced alliances between practitioners. Facilitating accurate medication histories – improved communication. (GPs, CPs, ACF) Liaising with GP Networks Kerry Fitzsimons 2010 Clinical pharmacists providing seamless continuity of care.

27. Medication Section of Electronic Discharge Summary (EDS)

28. Medication Profile