© Institute for Safe Medication Practices Canada 2009® Preventing Adverse Drug Events (ADEs) through Medication Reconciliation State of the Nation – National Teleconference April 2009

© Institute for Safe Medication Practices Canada 2009® Slide 2 Objectives To provide updates, developments, issues and learning from the intervention leadership team: Marg Colquhoun, Olavo Fernandes, Brenda Carthy & Alice Watt To encourage measurement appropriate to your MedRec model To celebrate what we have accomplished

© Institute for Safe Medication Practices Canada 2009® Slide 3 Agenda Medication Reconciliation Updates: State of the Nation Acute Care Long Term Care (LTC) Tools Measurement Update Clarity, Frequency and Duration Moving on with Medication Reconciliation…… Transfer, Discharge, Homecare Pilot, Ambulatory/ Community, High 5’s Open Forum : Q & A’s

© Institute for Safe Medication Practices Canada 2009® Slide 4 What impact has SHN had in Canada? “Thousands of practitioners are collaborating, sharing, learning, implementing safe practices and improving safety” Phil Hassen, CEO CPSI Accomplishment Report

© Institute for Safe Medication Practices Canada 2009® Slide 5 SHN Medication Reconciliation Teams As of March 2009 Acute Care: 320 Long Term Care: 84 Home Care: 15 Total = 419 Canadian Teams

© Institute for Safe Medication Practices Canada 2009® Slide 6 Med Rec Accomplishments Dr. Chaim Bell - CIHR research project University Health Network – National Commitment to Care Award Vancouver Coastal Health Providence Healthcare – 3M Healthcare Quality distinction award Send us ones we do not know about!

© Institute for Safe Medication Practices Canada 2009® Slide 7 Acute Care Lilly Hospital Pharmacy National Survey Results (n=158) Seventy-one percent (71%), of respondents are registered as participating in the Safer Healthcare Now! medication reconciliation intervention

© Institute for Safe Medication Practices Canada 2009® Slide 8 Long Term Care Atlantic Node just completed a successful LTC Collaborative with > 20 teams Ontario Node leading a project in fall 2009 with ~ 14 teams Kaizen project in Toronto

© Institute for Safe Medication Practices Canada 2009® Slide 9 What We’ve Learned MedRec decreases the potential for ADEs MedRec requires training Why MedRec? Get your own cases, use your own data How it is done in your organization BPMH training is vital People are beginning to expect MedRec

© Institute for Safe Medication Practices Canada 2009® Slide 10 Accreditation Canada Evidence of Compliance Changes Triage and Clinics Currently preparing ROP information for consultation with content experts and organizations Accreditation Canada views this work as a priority and that updated information will be released over the next few weeks

© Institute for Safe Medication Practices Canada 2009® Slide 11 International Med Rec- High Fives CPSI/ ISMP Canada is also collaborating with the World Health Organization on medication reconciliation ‘Assuring Medication Accuracy at Transition in Care’ for the WHO/Joint Commission International High 5s Being launched in June 2009 Will be recruitment of Canadian teams

© Institute for Safe Medication Practices Canada 2009® Slide 12 Med Rec Communities of Practice (CoP)

© Institute for Safe Medication Practices Canada 2009® Slide 13 The medication reconciliation CoP has garnered over 1,000 members since its launch just three years ago. CoP Membership

© Institute for Safe Medication Practices Canada 2009® Slide 14 Med Rec COP Usage by Month The site receives upwards of 18,000 visits per month with numerous members engaging in helpful discussion threads.

© Institute for Safe Medication Practices Canada 2009® Slide 15 New Community of Practice FAQ’s based on 3 years of experience Greater capacity Growing pains Tutorials

© Institute for Safe Medication Practices Canada 2009® Slide 16 New CoP Issues Login to the new CoP If you need help contact Brenda Carthy at Reaching our members Set an alert for the Announcements. Instructions are available in the HELP section. Send feedback to

© Institute for Safe Medication Practices Canada 2009® Slide 17 CoP Help

© Institute for Safe Medication Practices Canada 2009® Slide 18 SHN Mentorship Program Mentorship program links successful teams to teams that require assistance with their programs Facilitates a one-on-one institution partnerships with teams/ institutions that have learnings/ successes they can share to mentor other teams Call for mentors and mentees Mentorship program links successful teams to teams that require assistance with their programs CoP has information Contact us if you are interested in participating

© Institute for Safe Medication Practices Canada 2009® Slide 19 Tools and Resources

New Wallet Card Coming Soon Medications: More Than Just Pills!!! Prescription Medicines These include anything you can only obtain with a doctor’s order such as heart pills, inhalers, sleeping pills.* Eye/Ear Drops Inhalers Nasal Spray Patches Liquids Injections Ointments/Cream Prompt the patient to include medicines they take every day and also ones taken sometimes such as for a cold, stomachache or headache. DON’T FORGET THESE TYPES OF MEDICATIONS Over-The-Counter Medicines *These include things that can be purchased at a pharmacy without an order from the doctor such as aspirin, Tylenol, laxatives, other bowel care products, herbs like garlic and Echinacea or vitamins and minerals like calcium, B12 or iron. AND Adapted from

© Institute for Safe Medication Practices Canada 2009® Slide 24 Additional Tools BPMH training Frequently Asked Questions: FAQ’s E learning packages under consideration Medication reconciliation introduction packages See the Community of Practice

© Institute for Safe Medication Practices Canada 2009® Slide 25 Measurement

© Institute for Safe Medication Practices Canada 2009® Slide 26 MedRec Teams Reporting to Central Measurement Team National Statistics: Average of 100 teams reporting every month to Central Measurement Team

© Institute for Safe Medication Practices Canada 2009® Slide 27 Measurement Activity

© Institute for Safe Medication Practices Canada 2009® Slide 28 The average rate of unintentional discrepancies decreased from 1.02 between November 2005 and June 2006, to an average rate of 0.61 discrepancies between May 2007 and December 2008.

© Institute for Safe Medication Practices Canada 2009® Slide 29 Over a 16-month period, the average rate of undocumented intentional discrepancies dropped from 0.77 to 0.48 and has been sustained for an additional 20 months.

© Institute for Safe Medication Practices Canada 2009® Slide 30 Measurement Learning from Teams Several similar interdisciplinary practice models or processes possible Important to distinguish for measurement purposes 1.Proactive Reconciliation 2.Retroactive Reconciliation 3.Hybrid model of 1 and 2

© Institute for Safe Medication Practices Canada 2009® Slide 31 Proactive Medication Reconciliation Process 1.Create the BPMH 2Using the BPMH, Admission medication orders (AMOs) are written by the prescriber. 3.Verify that the prescriber has assessed every medication on the BPMH, identifying and resolving any outstanding discrepancies with the prescriber, if any. BPMH Admission Orders STEP 1STEP 2STEP 3 Verify every medication in BPMH has been assessed by prescriber. PROACTIVE MEDICATION RECONCILIATION MODEL LEADS TO

© Institute for Safe Medication Practices Canada 2009® Slide 32 Retroactive Medication Reconciliation Process 1.Primary medication history is taken 2.Admission medication orders are written by prescriber 3.Create the BPMH 4.Compare the BPMH against the patient’s admission medication orders, identifying and resolving any discrepancies with the prescriber. STEP 4 Compare BPMH with AMOs and resolve any discrepancies Primary Medication HIstory Admission Orders BPMH STEP 1STEP 2STEP 3 RETROACTIVE MEDICATION RECONCILIATION MODEL LEADS TO

© Institute for Safe Medication Practices Canada 2009® Slide 33 Measurement Learning Everyday reconciliation process and measurement process are actually distinct and different activities After baseline, team needs to measure after reconciliation in order to measure the improvement

© Institute for Safe Medication Practices Canada 2009® Slide 34 When should you measure ?

© Institute for Safe Medication Practices Canada 2009® Slide 35 When to measure? (unintentional and undocumented intentional discrepancies) Done after the team has completed its normal or standard reconciliation processes Second person Independent of clinician who has done the main reconciliation Resource requirements - meant to be low intensity Performed on a very small sample (subset of patients) monthly for a finite period of time only Can be from same clinical area, different clinical area, quality / patient safety staff member Aim is to measure the quality of medication reconciliation To ensure medication discrepancies have all been identified (no need to count discrepancies team has identified and are in the process of being resolved) Look at all available patient information - no need to repeat BPMH, clarify with team as necessary

© Institute for Safe Medication Practices Canada 2009® Slide 36 When to Stop/ Change Frequency of Measuring Unintentionals? Reached its 1) measurement goal (original relative target definition) or 2) reached 0.3 unintentional discrepancies per patient (absolute target- average 75 th percentile for MedRec 2 for calendar 2008) Held its gains for 3 consecutive data points (months) in a 3-6 month period is considered to be “At Goal”. Teams at goal can start/ continue to measure % of patients with formal reconciliation at admission (regularly) Should then ensure quality is maintained by reinstituting discrepancy measurement twice/year

© Institute for Safe Medication Practices Canada 2009® Slide 37 New Measure for Admission Medication Reconciliation Added to align / synchronize with Accreditation Canada performance indicators (same definitions) % patients receiving formal medication reconciliation on admission Denominator is total admissions (can be by unit or institution)

© Institute for Safe Medication Practices Canada 2009® Slide 38 Moving On Transfer medication reconciliation Discharge medication reconciliation E-learning Ambulatory care Homecare

© Institute for Safe Medication Practices Canada 2009® Slide 39 MedRec at Transfer and Discharge Feedback from teams: many have started and moved toward sustaining admission med rec and are now earnestly focused on transfer and discharge National Calls Upcoming – revisit principles, processes and tips on these interfaces Teams sharing their successes, lessons learned and processes Studies completed and in progress

For Consideration: Ambulatory Medication Reconciliation Model For Consideration: Ambulatory Medication Reconciliation Model Creating the most “up to date” medication record (BPMH) (From SHN Home Care Pilot) Patient and Family Interview Medication Information from all other sources document “up to date” medication record (BPMH) “medication discrepancies that require clarification” Compare: Review and follow up where indicated Examples: Medication vial inspection Referral record Community pharmacy Hospital Discharge Summary

© Institute for Safe Medication Practices Canada 2009® Slide 41 Medication Reconciliation Homecare Evidence shows significant issues with medication errors in home care. SHN! is exploring the issue in the home and community care realm in a pilot project

© Institute for Safe Medication Practices Canada 2009® Slide 42 Aim of Pilot Project Develop/validate framework to aid homecare providers in the implementation of medication reconciliation into care delivery processes. This framework is to take into consideration the unique challenges of the homecare delivery setting in Canada. This is being done by exploring developing and testing medication reconciliation strategies for implementation in the homecare setting.

© Institute for Safe Medication Practices Canada 2009® Slide 43 What are the teams doing? Applying a structured medication reconciliation process to targeted client populations Testing tools, guides and measures to determine what works and what does not work in the home care setting. Collecting data in order to identify processes for improvement throughout the pilot Identifying the challenges that are unique to applying medication reconcilation processes in this sector

© Institute for Safe Medication Practices Canada 2009® Slide 44 Early Successes Positive impact on clinicians Clinicians are beginning to spread the word outside the pilot that this is best practice Success with strategies for physician engagement With familiarity, process time is decreasing Preliminary data demonstrates that medication reconciliation is needed in the homecare sector

© Institute for Safe Medication Practices Canada 2009® Slide 45 OVERALL VIEW: Measure Three Percentage of Discrepancies that require clarification

© Institute for Safe Medication Practices Canada 2009® Slide 46 OVERALL VIEW: Measure Two Time to Complete the BPMH

© Institute for Safe Medication Practices Canada 2009® Slide 47

© Institute for Safe Medication Practices Canada 2009® Slide 48 Please contact Brenda Carthy for CoP issues Please send your address to Brenda Carthy