1. MedsCheck and Hospital Medication Reconciliation Improving Patient Safety Building the Community Pharmacy and Hospital Partnership Ottawa Ontario Oct. 14, Margaret Colquhoun Project Leader ISMP Canada

2. ISMP Canada www.ismp-canada.org
To identify risks in medication use systems, recommend optimal system safeguards and advance safe medication practices.
Work to advance safe medication use.

3. Agenda Welcome and Introductions Medication reconciliation
Overview and progress of work in institutions including discharge medication reconciliation
3. MedsCheck and Medication Reconciliation Pre-surgical MedsCheck for elective surgical patients – who, what, how?
4. Planning Together
Summary and next steps
Staying in touch

4. Medication Reconciliation
Formal and consistent process in which most accurate list of patient’s home medications are compared at transitions of care: admission, transfer, discharge, LTC, homecare
Discrepancies are identified, brought to attention of physician, required changes are made and communicated
Intended to minimize potential patient harm from unintended discrepancies

5. Medication Reconciliation
Is also…
A high priority objective for all hospitals in Ontario
A Required Organizational Practice for Accreditation Canada
One of the Safer Healthcare Now! Initiatives
A process that will become the new way…not a project

6. Primary Medication History: MD or RN Admission Reconciliation
Schematic of Structured, Multidisciplinary Integrated Medication Reconciliation Strategy
Primary Medication History: MD or RN ER
Ward
BPMH:
Taken by pharmacist
Admission Reconciliation
BPMH medical chart
One history only 1
Wong J. Annals of Pharmacotherapy 2008 (in press)

8. Published Studies: “Unintended Medication Discrepancies at the time of Hospital Admission”
151 patients
At least 4 regular prescriptions, admitted to GIM teaching hospital
53.6% of patients at least 1 unintended discrepancy
[95% CI 45.7%-61.6%]
46.4% of errors – omitted medication
Patient Impact : 38.6% had the potential to cause moderate to severe discomfort or clinical deterioration
Cornish P et al. Arch Intern Med 2005:165;

9. Published Studies: “Patient Medication Adverse Events Post Discharge”
23% of Discharged Patients from a Canadian Hospital experienced an adverse event – of those 72% were drug related
328 patients who were discharged from a Canadian teaching hospital were studied prospectively in 2002 for 14 weeks. (AJ Forster,et al., CMAJ 2004:170(3) )
Developed by Courtyard-Group for E-Health Conference 2004

10. Published Studies: The Case for Medication Reconciliation
Many patients (70%) not receiving medication instructions at discharge
(Alibhai SMH, Han RK, Naglie G. Medication Education of Acutely Hospitalized Older Patients. J Gen Intern Med 1999 Oct;14: )

11. Glaucoma meds missed for 14 days
Stories from Medication Reconciliation Teams: Medication reconciliation Failures
Transplant rejection drugs not ordered on admission (>48hr delay in restarting)
Glaucoma meds missed for 14 days
#1 Kidney transplant patient admitted and rejection drugs not continued for >48hrs. Med rec in 24hrs would have solved this quicker. Potential for harm very real and very great.
#2 Patient transferred from RGH to PH under care of family physician. Med rec process identified pts glaucoma eye drops not ordered or given for 2 weeks. Potential for harm – real.
#3 Hydromorphone 3mg q12h at home transcribed as 30mg q12h on admission. Pharmacy processed orders. Patient was admitted on a Friday afternoon and was given one dose Friday night and another Saturday am. Family arrived Saturday and took patient out on pass and called in a few hours later stating the patient had become lethargic with decreased responsiveness. Family was directed to take patient to ER for assessment – observed for several hours and back to normal. Patient taken back to LTC facility and received Saturday pm dose and Sunday am dose – once again unresponsive and then the problem was found.
#4 Elderly patient was admitted with newly diagnosed afib and had simple hospital course saw rate control calcium channel blocker therapy changed from amlodipine to diltiazem. Patient not informed of change and went home and took both. Readmitted 3 days later due to severe bradycardia and nearly required pacemaker.

12. Med Rec Admission Failure
LB was admitted to a medical ward with a working diagnosis of community acquired pneumonia
Appropriate antibiotics & symptom management ordered & commenced
2 days later LB suffered a myocardial infarction (HR 168)
Beta-blocker was not continued on admission

13. Current Picture
We do not have seamless communication systems…………and patients know it
There is duplication of effort in community and hospital
There is potential for unintended adverse drug events

14. What is the patient supposed to be on?
Hospital Perspective
What is the patient supposed to be on?
Patient Interview
Labels on Rx Vials
Medication Lists
Family MD list
Patient’s own list
Patient’s Actual Medication Use
Medical chart
Medication wallet
cards
Community pharmacist
Patient’s Prescribed Medication Regimen 
What is the “truth”?

15. Community Perspective
What is the patient supposed to be on?
Other sources of information:
Patient profile on the computer (not reflective of recent changes)
Patient or agent (usually know little)
Hospital Physician /Nursing station (impossible to acquire info)
RX’s from the hospital
Missing information (medication name, dose, frequency, quantities LTD codes)
Illegible
Automatic substitutions while in hospital
Drugs not covered by ODB or drug plan
Section 8’s not applied for
Knowing which meds were intentionally discontinued or were they unintentionally missed

16. MedsCheck Ontario Ministry of Health and Long-Term Care
Funded by MOHLTC
One-on-one 30 minute appointment with the community pharmacist
Reviews all the patient’s medications (prescribed and OTC)
Helps patients better understand their medication therapy and ensure that medications are taken as prescribed.

17. Who is eligible for a MedsCheck?
All Ontarians are eligible
Once per year
No additional cost to client
Provided they are taking 3 or more medications for a chronic condition.
Community Pharmacist is reimbursed for their professional services.

18. MedsCheck Personal Medication Record

19. What’s a MedsCheck Follow-up?
MedsCheck Follow-up is a program for patients who may benefit from additional MedsChecks during the annual timeframe.
There is no limit to the number of Medscheck Follow-ups provided they meet the following criteria:
A planned hospital admission (e.g. elective surgery)
A physician or registered nurse in the extended class (RN[EC]) request
A recent discharge from hospital (within 2 weeks)

20. Overview of MedsCheck/Medication Reconciliation Pilot
To facilitate the linkage of the MedsCheck program in community pharmacies with the medication reconciliation process in hospitals in communities across Ontario.

21. Pilot Objectives To Improve : Communication of medication information
Continuity of care for the patient/client at transitions of care.
Accuracy of medication ordering
Efficiency by reducing re-work

22. Linking MedsCheck to MedRec Pilot ISMP Canada 2008
14 hospitals
Pre-admission surgical clinic - elective patients
Requesting patients to arrange a MedsCheck 1-2 weeks prior to their pre-admission clinic appointment
Create the Best Possible Medication History (BPMH) in hospital using MedsCheck as the primary source of information
Collect data - time to complete BPMH and quality of MedsCheck

23. Our Initial Focus: Pre Surgical Admission Reconciliation1
Pre-op
Appointment 1
Prevent inadvertent omission of needed home meds
Prevent errors associated with orders having incorrect doses or dosage forms
Day of
Surgery OR 2 1
Prevent failure to restart home meds following discharge and transfer
Prevent duplicative therapy at discharge (i.e. brand/generic, formulary substitutions) 2
Surgical Unit
Transfer Units (Rehab) 2
Home

24. Co-ordination Process Flow
Patient gets
a MedsCheck 2 weeks before pre-op clinic date
Pt brings MedsCheck and vials
to pre-op clinic date
Surgeon asks
Pt to get a
MedsCheck
BPMH created using MedsCheck plus 1 other source
UPDATE:
Booklets
Pamphlets
Hip/Knee binders
Verbal reminders
Hospitals:
Phone reminders
Calling/Faxing their pharmacies
Day Surgery nurse
reviews medication
list with patient
on day of surgery
POST-OP
Surgeon reviews and orders meds using BPMH
BPMH is updated
Discharge
MedRec
Patients sees community pharmacist for MedsCheck Follow-up

25. Supports for Hospitals
Checklists
Revised sample forms
Data collection tools pre and post MedsCheck
Community pharmacists BPMH presentations and meetings such as this one
Sharing teleconferences

26. Sample: My Total Joint Replacement Passport
Transportation
Appointment with your surgeon for postoperative follow-up visit
Anticoagulation therapy stop date
Staples/clip removal date
Discharge date from hospital
Community Care Access Centre (CCAC) visit or Outpatient Physiotherapy postoperative appointment
MedsCheck appointment with your community pharmacist (if you are on 3 or more prescribed meds)
Appointments with specialists
Appointment with your family doctor
Preoperative assessment
Date of surgery
Date
Appointment/Activity
My Total Joint Replacement Passport
Please use this passport to record the dates for all of your appointments and other activities. The next page explains each appointment / activity in more detail.
My surgeon is Dr. _________________________. His/her office will contact me with my surgery date.
My family member/friend who will assist me throughout my joint replacement is: _______________________.
He/she can be reached at: _________________.
Bring this passport with you to all appointments.
Used with permission from Markham Stouffville hospital

28. Sample: Forms and Applications
The forms and applications must be completed before your preoperative visit to the hospital. If you have any questions, it is fine to contact your surgeon’s office for assistance.
These forms must be brought with you to your preoperative assessment visit at the hospital:
History and Physical Form
Anesthesia Patient Questionnaire
Inpatient Rehabilitation Application
MedsCheck from your community pharmacist if you are on 3 or more prescribed medications

29. Sample: Surgical Assessment Clinic (SAC) Checklist
Translator - If your primary language is not English, please arrange to have a translator with you for all your appointments including on the day of your surgery.
A family member, friend, or caregiver who will be helping you after surgery.
A snack and drink as you will be at the hospital for 4-5 hours; this is particularly important if you have diabetes.
MedsCheck from your community pharmacist if you are on 3 or more prescription medications.
All medications you are taking at home in their original containers with the labels (include prescription eye drops and creams, herbal and over-the-counter medications).
Copies of any recent blood work or diagnostic tests that you have had done outside of Markham Stouffville Hospital.
History and Physical form – completed by your family physician.
The Anesthesia Patient Questionnaire – completed by you.
Rehabilitation Application – completed by you.
The forms given to you with this guide are to be brought in with you to the SAC appointment or returned prior to the appointment. If you have mailed or faxed these forms, you must ensure they reach the hospital before this appointment.
Surgical Assessment Clinic (SAC)
Appointment Checklist
What to Bring with You
Bring this patient guide with you. Your orthopedic team will review your passport with you to ensure you are completing all of your presurgical preparations correctly.
Used with permission from Markham Stouffville hospital

30. Coordinating MedsCheck and Medication Reconciliation in Ontario will:
Positively impact the entire continuum of patient care:
Seamless transfer of information
Support patients to take/receive medications correctly and appropriately during transitions in care.
Reduce the potential for medication errors/adverse drug events
Improves efficiency and accuracy

31. Coordinating MedsCheck and Medication Reconciliation in Ontario will:
Develop and strengthen the relationship between patients and their community pharmacist.
Improve patients understanding of their medications by reviewing them in the community and again in hospital at discharge.
Encourage hospital and community pharmacies to work more closely together to improve communication and patient care.

32. Hospital Roles
Change processes to direct patients to book a MedsCheck prior to pre-admission clinic date.
Surgeons, pre-admit nurses, forms and tools
Pilot hospitals have resources to share E.g Checklist
Train preadmission staff to ask for a MedsCheck by name when doing BPMH and use it.
Further implement discharge medication reconciliation

33. Community Pharmacists Role
Book MedsCheck for pre-admission clinic patients when they ask or if contacted by the hospital
Perform MedsCheck
Record all the medications the patient is actually taking. If it differs from the prescribed instructions then document the discrepancy in comments section.
Include all current prescription and over-the-counter medications. (aspirin, iron, potassium)
Ask about medications dispensed from other pharmacies.
Perform Follow-up MedsCheck at Discharge within 2 weeks

34. Innovations we’ve heard about - hospitals
Using SPEP students to follow patient from SAC visit to admission
Using volunteers to phone patients to remind them to get a MedsCheck
Phoning/faxing pharmacies (with the patient’s permission) to inform them of the patients who are having a surgery and their pre-admission clinic date
Writing articles in local paper about this new initiative to inform patients
Faxing community pharmacies a form to fax back so that it is completed in the hospital format as that you would use in hospital. (Note: some community pharmacies are using electronic version)
Working with community pharmacists on discharge med rec form.

35. Innovations we’ve heard about……community
Designated MedsCheck day - considered a viable business plan that pays for itself
SPEP Students - good educational experience
Scheduling daily time for MedsCheck
BPMH training (Enhancing MedsChecks)
Accommodating patients who cannot get a MedsCheck from their own pharmacy

36. Making it Happen What are the barriers in hospitals?
What are the barriers in community to accommodating more patients for a MedsCheck or complying with patient/hospital request to book a MedsCheck?
How can we work together?

37. Conclusion We have opportunities in Ontario to help us overcome the
challenges of medication
information transfer

38. Questions
mcolquhoun or