1. Medication Reconciliation in Continuing Care Getting It Right Together Creating a Culture of Safety September 8, 2008 Dr. Paula Creighton MD, FRCP(C) Geriatric Medicine Specialist Cape Breton District Health Authority

2. September 2008Dr. Paula CreightonPage 1 Outline Understand why Medication Reconciliation is getting so much attention through: Understanding how adverse drug events (ADEs) commonly occur Identify practical steps that can reduce the risk of ADEs in practice Identify key features of a safer system

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5. September 2008Dr. Paula CreightonPage 4 Definition Adverse Event UNINTENDED act or event during care May result in potential harm Harm = increase length of stay = temporary/permanent disability = death

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7. September 2008Dr. Paula CreightonPage 6 How ADEs occur? Increase range of medicines to treat or prevent disease Multiple co-morbid conditions Age-related changes physiology Tsilimingras, Rosen, &. Berlowitz 2003. Canadian Patient Safety (CPSI) Institute 2006

8. September 2008Dr. Paula CreightonPage 7 How ADEs occur? Multiple health care practitioners Frequent visit to hospital setting (hospitalization, procedures, tests) Adherence problems Tsilimingras, Rosen, &. Berlowitz 2003. Canadian Patient Safety (CPSI) Institute 2006

9. September 2008Dr. Paula CreightonPage 8 How ADEs occur? OTC medication use Impaired vision, dexterity, literacy Tsilimingras, Rosen, &. Berlowitz 2003. Canadian Patient Safety (CPSI) Institute 2006

10. September 2008Dr. Paula CreightonPage 9 When ADEs occur? Entry and exit points of clinical encounters Cornish P. et al Arch Intern Med 2005:165; 424-429

11. September 2008Dr. Paula CreightonPage 10 Labels Lists Verbal (open ended inquiry) Someone else has/will complete Traditional Medication History

12. September 2008Dr. Paula CreightonPage 11 Limitations to Traditional Medication History Discrepancies: Unintentional Undocumented Intentional

13. September 2008Dr. Paula CreightonPage 12 Unintentional Discrepancies Over-the-counter medications Shared prescriptions Labels “as directed” Prescription change without script Samples

14. September 2008Dr. Paula CreightonPage 13 Undocumented Intentional Discrepancies What changed and why? Convey a clear understanding of desired outcomes to therapy. Written communication with patient/family and pharmacist

15. September 2008Dr. Paula CreightonPage 14 Get Involved Now! safer healthcare

16. September 2008Dr. Paula CreightonPage 15 Key Features toward a Safer System Change

17. September 2008Dr. Paula CreightonPage 16 Key for a Safer System Doing our jobs differently… …If you always do what you have always done; You always will get what you always got

18. September 2008Dr. Paula CreightonPage 17 Practical steps to reduce risk of ADEs “To prescribe according to best evidence from scientific research and to be mindful of the precepts of patient autonomy” Holland R, Wright D. Medication Review for Older Adults. Geriatrics and Aging March 2006, Vol 9. No.3.

19. September 2008Dr. Paula CreightonPage 18 Practical steps to reduce risk of ADEs When might it be best to withhold or discontinue medications that are otherwise appropriate on the basis of guidelines?

20. September 2008Dr. Paula CreightonPage 19 Practical steps to reduce risk of ADEs Consider life expectancy Goals of care and quality of life defined by patient/family Potential benefit & risk of medications

21. September 2008Dr. Paula CreightonPage 20 Practical steps to reduce risk of ADEs Start low, Go slow, Or don’t start at all!

22. September 2008Dr. Paula CreightonPage 21 Practical steps to reduce risk of ADEs Partnering with Patients “Nothing about me, without me” (author unknown)

23. September 2008Dr. Paula CreightonPage 22 Medication Reconciliation Partnering with Patients patient/family interview

24. September 2008Dr. Paula CreightonPage 23 Practical steps to reduce risk of ADEs Humans require formal cues/processes to stay on track reliably Reliable work processes account for the known imperfections of humans Adapted from PSO Training Course (IHI) 2004

25. September 2008Dr. Paula CreightonPage 24 Medication Reconciliation MEDICATION RECONCILIATION: include on list below Over the counter products, Samples, Shared pills Drug Name Drug Strength When Taken Indicate if: -New -Change from label -Effects from new and change MorningNoonEveningBedtime 1 2 3 4 5 6

26. September 2008Dr. Paula CreightonPage 25 Threats for Change toward a Safer System Power Gradient Fear (Mis)-Perception “touchy, feely” initiatives

27. September 2008Dr. Paula CreightonPage 26 Key for Change toward a Safer System Self audit: More mirrors and fewer windows

28. September 2008Dr. Paula CreightonPage 27 Self Audit "One of the major impediments to convincing people of the prevalence and seriousness of cognitive error is the faith they have in their own thinking abilities" Croskerry, P. The Science of Human Factors in Healthcare, QHN, October 2003

29. September 2008Dr. Paula CreightonPage 28 Key for Change toward a Safer System “ Many little people Doing many little things In many little places Can change the world.” (Chinese Proverb; author unknown) Susan Sheridan, Chair, Patients for Patient Safety Strand, WHO World Alliance for Patient Safety; Co-Founder, Consumers Advancing Patient Safety, Eagle, Idaho

30. September 2008Dr. Paula CreightonPage 29 Get Involved Now! safer healthcare