1. Medication Use in Rural Health America Conference Improving Medication Reconciliation in Small Rural Hospitals: Using a Systematic Approach Howard J. Eng, MS, DrPH, RPh Arizona Rural Hospital Flexibility Program Rural Health Office Mel and Enid Zuckerman College of Public Health The University of Arizona June 17, 2010

2. Presentation Overview 1.Medication Reconciliation Definition 2.Project Goals 3.Six Steps of the Systematic Approach 4.Project Results Disclosure Statement: The presenter has no conflict of interest to report.

3. Pre-Presentation Quiz (Circle all the answers that applies) 1.What is included in the medication reconciliation list related to the drug? a. Name b. Manufacturer c. Dosage d. Frequency e. Cost 2.How many primary medication reconciliation encounter points are there in small rural hospitals? a. Three b. Four c. Five d. Six e. Seven 3.How many assessment steps are there in the Arizona Flex Medication Reconciliation Improvement Approach? a. One b. Two c. Three e. Four f. Five 4. Who should be included in the medication reconciliation procedure changes? a. Pharmacists b. Nurses c. Physicians e. Hospital Administrator 5.What will be impact of an effective medication reconciliation system? a. Improve safety b. Increase drug numbers c. Increase cost d. Reduce errors

4. Medication Reconciliation Definition The process of identifying the most accurate list of all medications a patient is taking, including name, dosage, frequency and route, and using this list to provide correct medications for patients anywhere within the health care system.

5. Project Goals 1.Improve the medication reconciliation procedures of the four participating hospitals. 2.Reduce hospital medication errors, and improve patient safety and quality. 3.Support by a Medication Reconciliation Working Group  Four participating hospitals  Arizona Hospital and Healthcare Association  Health Services Advisory Group (Arizona’s QIO)  Arizona Pharmacy Alliance  Managed Care Pharmacy Consultants 4.Develop a systematic approach to improve medication reconciliation that other small hospitals can use.

6. Four Participating Hospital Locations Bisbee Douglas Page Winslow

7. Pharmacist Coverage Comparisons 1. Copper Queen Community Hospital  On-site pharmacist coverage on Monday, Tuesday, and Friday from 8:30 a.m. to 5:00 p.m., and pharmacist is on call the rest of the time. 2. Little Colorado Medical Center  On-site pharmacist coverage seven days a week during the hours of 7:00 a.m. to 3:30 p.m., and pharmacist is on call the rest of the time. 3. Page Hospital  On-site pharmacist coverage Monday through Friday from 8:00 a.m. to 5:00 p.m., Saturday and Sundays from 8:00 a.m. to 3:00 p.m., and pharmacist is on call the rest of the time. 4. Southeast Arizona Medical Center  Off-site pharmacist coverage 24 hours a day and 7 days a week.

8. Medication Use in Rural Health America Conference Using a Systematic Approach to Improve Medication Reconciliation Procedures in Small Rural Hospitals

9. Six Step Approach 1.Rural Hospital Medication Reconciliation Risk Assessment Survey (May 2006) 2.On-site visits to assess the hospital’s medication reconciliation procedures (June 2006) 3.Rural Hospital Medication Safety Assessment Survey (July 2006) 4.Medication reconciliation area(s) selection (July 2006) 5.Medication reconciliation intervention(s) implementation (July 2006 to December 2006) 6.Intervention Evaluation (December 2006)

10. Six Step Approach 2. On-Site Visits to Assess Med. Recon. Process 5. Med. Recon. Procedure(s) Changed 3. Med. Safety Assessment Survey 6. Med. Recon. Procedure(s) Evaluation 1. Med. Recon. Risk Assess Survey 4. Med. Recon. Procedure Selection

11. Medication Use in Rural Health America Conference Rural Hospital Medication Reconciliation Risk Assessment Survey

12. Hospital Medication Reconciliation Process Patient 1. Patient Admission Record current medications 4. Nurse Checks and administers medications 5. Nurse Checks and adds home medications 2. Physician Reviews and orders Rx medications 3. Pharmacist Reviews and fills Rx med orders 6. Patient Discharge Review and discuss meds

13. Rural Hospital Medication Reconciliation Risk Assessment Upon Admission Record Meds Physician Review and order meds Pharmacist Review and fill med order Nurse Check and administer meds Nurse Check and add home meds Upon Discharge Review meds What is done? When is it done? Who does it? Where is it done? How is it done? Use a Recording Form

14. Rural Hospital Medication Reconciliation Risk Assessment: Upon Admission Records Current Medications Summary Copper Queen Community Hospital (Bisbee) Southeastern Arizona Medical Center (Douglas) Page Hospital (Page) Little Colorado Medical Center (Winslow) What is done? (e.g., record current prescription drugs, over-the- counter drugs, and herbs) Full admits with data base EROs done in ER on admit form ER-Med. list obtained – documented on ER Assessment Sheet In-Pat.-Meds. documented on Med. Rec. form Record home meds including OTC Admitting nurse gathers medication history When is it done? (e.g., within 2 hours of patient being admitted) Upon admissionUpon admission to ER and within two hours of admission to In-pat. status On AdmissionUpon initial evaluation by hospital staff- typically within 30 minutes of check-in Who does it? (e.g., admitting nurse records all medications and herbs) Nurse and sometimes Spanish-speaking CAN In-pat. admitting nurse will document on Med. Rec. form RN / RPhAdmitting nurse Where is it done? (e.g., admitting nurse records this information in the patient’s room) In patient’s roomAdmitting Nurse documents assessment and Meds. in patient’s room Patient Chart/ComputerEither in the ED or on the Med./Surg. unit in the case of a direct admission How is it done? (e.g., admitting nurse records information on patient medication profile form) Ward clerk transcribes to MAR, RN checks Admit. Nurse records info. on Med. Rec. form and on MAR Written on chart/entered into computer On a Med. Rec. form, if they remember and forms are available Use a Recording Form Please circle Yes or No If yes, please provide a copy. Yes Yes (most of the time)

15. Medication Use in Rural Health America Conference Rural Hospital Medication Reconciliation Risk Assessment Exercise

16. Hospital Visitations

17. Southern Hospital Visits: June 13, 2006 Douglas-Agua Prieta Border Crossing (bottom left) and Bisbee - Lavender Pit Mine (bottom right)

18. Southeast Arizona Medical Center Visit: June 13, 2006 Hospital (top left), Pharmacy (top right), Nursing Station (bottom left), and MC Pharmacy Team (bottom right)

19. Copper Queen Community Hospital Visit: June 13, 2006 Hospital (top left), Pharmacy (top right), Nursing Station (bottom left), and MC Pharmacy Team (bottom right)

20. Northern Hospital Visits: June 20-21, 2006 Page - Glen Canyon Dam (bottom left), and Winslow - Meteor Crater (bottom right)

21. Page Hospital Visit: June 20, 2006 Hospital (top left), Pharmacy (top right), Nursing Station (bottom left), and MC Pharmacy Team (bottom right)

22. Little Colorado Medical Center Visit: June 21, 2006 Hospital (top left), Pharmacy (top right), Nursing Station (bottom left), MC Pharmacy Team (bottom right)

23. Medication Use in Rural Health America Conference Rural Hospital Medication Safety Assessment Survey

24. Rural Hospital Medication Safety Assessment Survey Modeled after the Pathways for Medication Safety Developed through a collaborative effort of the American Hospital Association, the Health Research Trust, and the Institute for Safe Medication Practices Examined seven medication-related areas Modified with very little cost to the hospital or little resources needed to improve patient safety Identified 28 sub-areas

27. Institute for Safe Medication Practices: Sample Medication Process Diagram

28. Rural Hospital Medication Safety Assessment Survey: Seven Areas Patient Information Drug Information Communication of Drug Orders and Other Drug Information Drug Labeling, Packaging and Nomenclature Drug Standardization, Storage and Distribution Medication Delivery Device Acquisition, Use and Monitoring Staff Competency and Education

29. Areas and (# of Sub-Areas)100-51%50-0%NA Will improve within next two months Patient information (3)4,2,40,2,000,0,0 Drug information (7)3,4,1,2,3,3,41,0,1,2,1,1,00,0,2,0,0,0,00,0,0,0,1,0,0 Communication of drug orders and other drug information (3) 2,2,12,2,30,0,0 Drug labeling, packaging, and nomenclature (3) 4,0,40,4,00,0,0 Drug standardization, storage, and distribution (6) 1,2,2,3,4,42,0,1,1,0,01,0,0,0,0,00,0,1,2,0,0 Medication delivery device acquisition, use, and monitoring (3) 0,4,33,0,10,0,01,0,0 Staff competency and education (3)3,3,41,1,00,0,01,0,1 Rural Hospital Medication Safety Assessment Survey: Results

30. Rural Hospital Medication Safety Assessment Survey: Result Summary 60.7% of the 28 sub-areas were addressed by at least three hospitals the majority of the time 39.3% of the 28 sub-areas were addressed by all four hospitals the majority of the time 2 of the 4 hospitals indicated that they were going to improve on seven sub-areas within the next two months

31. Medication Use in Rural Health America Conference Rural Hospital Medication Project Selection

32. Medication Reconciliation Project Selection All four hospitals had medication reconciliation procedures in place at the six medication reconciliation encounter points. Upon admission, current medications are recorded Physician reviews and writes medication orders Pharmacist reviews and fills medication orders Nurse administers medications from orders Nurse administers patient home medications, as needed At patient discharge, medications are discussed and reviewed Each hospital recognized that there were medication reconciliation procedures that could be improved. The four hospitals selected as their project the medication history form upon admission as one of the medication procedures that needed to be revised. The hospitals developed and implemented a new medication history form upon admission that would also serve as the initial medication order and discharge form for three of the four hospitals.

33. Medication Use in Rural Health America Conference Rural Hospital Medication Project Implementation

34. Medication Reconciliation Project Implementation The Flex Program provided small grant funding to each of the hospitals to support the medication reconciliation procedure change(s). There was no standardized medication history form developed among the four hospitals because each hospital setting was unique. The four hospitals’ revisions of their medication history form were at different stages of development and implementation. The hospitals’ needs were different. The hospital departments using revised forms were different. The incorporation of the forms into the hospital patient electronic medical records was at different stages – two hospitals had an electronic medical record available and the other two had no such system. Each hospital established its project completion date and what would be considered a successful project outcome.

35. Medication Use in Rural Health America Conference Rural Hospital Medication Project Evaluation Results

36. Medication Reconciliation Project Evaluation The project evaluation (assessment) was done to determine the success of implementing the revised forms by December 31, 2006. Three of 4 hospitals met their target date for full multiple use form implementation. The fourth hospital continued to work toward full implementation of the form. The multiple use form implementation will improve medication reconciliation in the 4 hospitals. The multiple use form will reduce hospital medication errors and improve patient safety and quality. A year later, all 4 CAHs had incorporated the new multiple use medication form into their hospitals (institutionalized). The systematic approach used has been shown to be effective in changing small rural hospital medication reconciliation procedures. This approach can be a model used by other small rural hospitals.

37. Medication Use in Rural Health America Conference Assessment of the Systematic Approach Exercise

38. Post-Presentation Quiz (Circle all the answers that applies) 1.What is included in the medication reconciliation list related to the drug? a. Name b. Manufacturer c. Dosage d. Frequency e. Cost 2.How many primary medication reconciliation encounter points are there in small rural hospitals? a. Three b. Four c. Five d. Six e. Seven 3.How many assessment steps are there in the Arizona Flex Medication Reconciliation Improvement Approach? a. One b. Two c. Three e. Four f. Five 4. Who should be included in the medication reconciliation procedure changes? a. Pharmacists b. Nurses c. Physicians e. Hospital Administrator 5.What will be impact of an effective medication reconciliation system? a. Improve safety b. Increase drug numbers c. Increase cost d. Reduce errors

39. Acknowledgements Four Critical Access Hospital (CAHs) CEO’s Jim Dickson -- Copper Queen Community Hospital Jeff Hamblen -- Little Colorado Medical Center Sandy Haryasz -- Page Hospital Mike Carter -- Southeast Arizona Medical Center Medication Reconciliation Hospital Teams Copper Queen Community Hospital – Ruth Kish and Mimi Nguyen Little Colorado Medical Center – Jason Gilray Page Hospital – Robert McCaffrey and Lisa Martin Southeast Arizona Medical Center – Glen Klinger, Annie Benson, Maria Moreno, Debbie Thornby, Mark Wilson, and Mimi Nyguyen Other Members of Working Group Arizona Hospital and Healthcare Association - Barbara Weber-Averyt, Project Director Arizona Pharmacy Alliance – Mindy Rasmussen, CEO Health Services Advisory Group (Arizona’s QIO) - Scott Endsley, Medical; Director, Systems Design Managed Care Pharmacy Consultants – Bill Fink, President Flex Program Team Jim Laukes Alison Hughes Joyce Hospodar Julie Jacobs

40. Medication Use in Rural Health America Conference Questions? Thank You!

41. Contact Information Howard J. Eng, MS, DrPH, RPh Director Southwest Border Rural Health Research Center Rural Health Office Mel and Enid Zuckerman College of Public Health P.O. Box 245177 1295 N. Martin Ave. Tucson, Arizona 85724 hjeng@email.arizona.edu (520) 626-5840