1. State of the Nation – National Teleconference
Preventing Adverse Drug Events (ADEs) through Medication Reconciliation
State of the Nation – National Teleconference
April 2009

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

3. Agenda Medication Reconciliation Updates: Measurement Update
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

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

5. SHN Medication Reconciliation Teams
As of March 2009
Acute Care: 320
Long Term Care: 84
Home Care: 15
Total = 419 Canadian Teams

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!

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

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

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

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

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

12. Med Rec Communities of Practice (CoP)

13. CoP Membership
The medication reconciliation CoP has garnered over 1,000 members since its launch just three years ago.

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.

15. New Community of Practice
FAQ’s based on 3 years of experience
Greater capacity
Growing pains
Tutorials

16. New CoP Issues Login to the new CoP Reaching our members
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

17. CoP Help

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
CoP has information
Contact us if you are interested in participating

19. Tools and Resources

21. 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
New Wallet Card Coming Soon

24. See the Community of Practice
Additional Tools
BPMH training
Frequently Asked Questions: FAQ’s
E learning packages under consideration
Medication reconciliation introduction packages
See the Community of Practice

25. Measurement

26. MedRec Teams Reporting to Central Measurement Team
National Statistics:
Average of 100 teams reporting every month to Central Measurement Team

27. Measurement Activity

28. The average rate of unintentional discrepancies decreased from 1
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.

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.

30. Measurement Learning from Teams
Several similar interdisciplinary practice models or processes possible
Important to distinguish for measurement purposes
Proactive Reconciliation
Retroactive Reconciliation
Hybrid model of 1 and 2

31. Proactive Medication Reconciliation Process
Create the BPMH
2 Using the BPMH, Admission medication orders (AMOs) are written by the prescriber.
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 1
STEP 2
STEP 3
Verify every medication in BPMH has been assessed by prescriber.
PROACTIVE MEDICATION RECONCILIATION MODEL
LEADS TO

32. Retroactive Medication Reconciliation Process
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 1
STEP 2
STEP 3
RETROACTIVE MEDICATION RECONCILIATION MODEL
LEADS TO

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

34. When should you measure ?

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

36. When to Stop/ Change Frequency of Measuring Unintentionals?
State of the Union Address - Medication Reconciliation
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 75th 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
Ginny and Olavo – meeting goal can be unit by unit – or as is said here full implementation

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)

38. Moving On Transfer medication reconciliation
Discharge medication reconciliation
E-learning
Ambulatory care
Homecare

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

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

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

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.

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

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

45. State of the Union Address - Medication Reconciliation
OVERALL VIEW: Measure Three Percentage of Discrepancies that require clarification

46. OVERALL VIEW: Measure Two Time to Complete the BPMH
State of the Union Address - Medication Reconciliation
OVERALL VIEW: Measure Two Time to Complete the BPMH

48. Please contact Brenda Carthy for CoP issues bcarthy@ismp-canada.org
Please send your address to Brenda Carthy