1. Medication Reconciliation July 12, 2005 Glenn Billman, M.D., Medical Safety Officer, Children’s Hospitals and Clinics of Minnesota

2. 2 First, do no harm….

3. 3 “Medicine used to be simple, ineffective and relatively safe. “Now it is complex, effective, and potentially dangerous.” Sir Cyril Chantler The Issue:

4. 4 Optimal care for patients requires totally effective communication regarding medication use among numerous people of varying disciplines in multiple locations over time including the families themselves. Our Challenge :

5. 5 Implement a Process that will ensure that patients and their caregivers possess the most accurate, and up to date medication list possible Our Aim: Implement Medication Reconciliation

6. 6 Definition 1: Medication Reconciliation Reconciliation is the process of comparing what medication the patient is taking at the time of admission or entry to a new setting or level of care, with what the organization is providing (admission or new medication orders) to avoid errors such as conflicts or unintentional omissions.

7. 7 Definition 2: Medication Reconciliation All medications appropriately and consciously continued, discontinued, or modified at all transitions of care.

8. 8 Why Should We Do This? 140 discrepancies in 81 patients (1.7/pt) 65 omissions 59 wrong dose/frequency 16 wrong drug 32.9% discrepancies rates as potentially moderate harm; 5.7% severe harm Arch Intern Med, Feb 2005

9. 9 Why Should We Do This? Ineffective medication reconciliation upon hospital admission up to 50% of medication errors up to 20% of future ADEs

10. 10 1) Increased Percent of Patients That Completed Medication Coordination Percent Baseline Time Why Should We Do This? Because It’s Doable !

11. Why Should We Do This? Because It Works !

12. 12  Potentially Preventable ADE  Non-Preventable ADE Medication Coordination Parent Education ADE Monitoring 4) An Increase In The Number Of Days Between ED Visits Related To ADE’s Why Should We Do This? Because It Works !

13. 13 Improve Ambulatory Medication List Improve Admission Medication List Improve Discharge Medication List Improved Accuracy of Medication List Why Should We Do This? Efficiency !

14. 14 Impact on ADE Low High Low High CPOE Automated ADE Monitoring Bar Code Reconciliation Pocket Formulary Preprinted Order Forms Zero Tolerance Ordering Standards Medication Competency Testing Intervention Database Diagnosis Specific Order Sets Dedicated Unit Pharmacist Order Entry Pharmacy Managed Protocols Medication Reconciliation Pharmacist Patient Interview Cost To Implement Do First Don’t Bother Investing In Safety Why Should We Do This? It’s Cost Effective !

15. 15 2005 NPSG Goal 8: Medication Reconciliation Accurately and completely reconciles medications across the continuum of care 8a: During 2005, for full implementation by January 2006, develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.

16. 16 2005 NPSG Goal 8: Medication Reconciliation Accurately and completely reconciles medications across the continuum of care 8b: A complete list of the patient’s medications is communicated to the next provider of service when it refers or transfers the patient to another setting, service, practitioner, or level of care within and outside the organization.

17. 17 Medication Reconciliation Is A Tool To Help Bridge Gaps That Occur At Transitions and Transfers of Care Process steps: The medication history is completed The physician reviews and acts upon each medication The medication orders are written A 2 nd person reviews medication history That 2 nd person resolves discrepancies

18. 18 Reconciliation Virtually all hospitals who have successfully addressed admission reconciliation have created a special form as part of the solution. These forms pretty much look alike.

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21. 21 What is included? Current home meds / OTC / Herbals, including dose, route & frequency Time of last dose Source of the information The medications ordered at admission An Assessment of patient compliance

22. 22 There is no perfect medication list. Quit thinking there is. Do not be paralyzed by trying to perfect the list. Steve Meisel, PharmD

23. 23 Who uses the form? The nursing staff or pharmacist use the form to collect information at admission. The physician uses the form as a reference and/or order when writing initial orders for medications. In some cases the form itself serves as the order form, thereby obviating the need to rewrite orders. Both physicians and nurses use the form throughout the patient’s stay as a reference.

24. 24 Source of the information The patient/family The patient’s pharmacy Previous medical records The patient’s medication bottles The physician’s office

25. 25 A completed Medication List is only the Half Way Point. Reconciliation is real work!

26. 26 A Big Problem Is Often Just Getting An Accurate Medication List Patient brings in incorrect list. Patient does not take what is marked on bottle. Patient does not know what is on and family, pharmacy not available. Wrong name of med on ED sheet. Med bottles don’t jive with what the patient says. Patient is unable to tell you. No family available. MD on call does not know either. Can’t call the pharmacy “after hours”.

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28. 28 The Intent and Value of Medication Reconciliation Is In Having An Accurate Medication List.

29. 29 Transfer Reconciliation Critical especially upon transfer in and out of intensive care and other specialty units As much as 60% of the care plan after transfer may be different than what the physician expects Can utilize internal computer systems to facilitate, but there must be an active decision to continue, discontinue, or modify each line item

30. 30 Transfer Reconciliation Automatic stops of certain critical- care-specific drugs (e.g. dopamine) are acceptable provided those stop orders appear in the medical record. ? Benzodiazepines Requirement to re-write all orders upon transfer introduces new opportunities for error

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32. 32 Discharge Reconciliation The patient’s reconciled list of admission medications is compared against the physician’s discharge orders along with the last day’s MAR. The lists can either come from the computer system or be integrated with the original admissions list.

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35. 35 To Be Successful: Put the patient first (this isn't someone else's job) You need to have some good change methodology to be able to develop a good product You need to use this to replace something else i.e. medication history in nursing data base

36. 36 Understand Your Processes Process flow Data flow Roles and responsibilities Procedures Build Incrementally – Start Small Leadership Support is Critical Project champions To Be Successful:

37. 37 You must have organization alignment (physician, nursing, pharmacy, administration) Process Owner and Sub-Process Owners A champion for the entire process Have a good education program when rolling it out Appropriately Resource the project You Need To Start! To Be Successful:

38. 38 Questions / Comments/ Discussion

39. Contact Information Contact Glenn Billman: glenn.billman@childrenshc.org