1. Continuity of Medication Management Spreading Medication Reconciliation Improvements Hospital Presenter Month YYYY

2. Continuity is an Issue in Health Care 10-67% of medication histories contain at least one error 1 Incomplete medication histories at the time of admission have been cited as the cause of at least 27% of prescribing errors in hospital 2 The most common error is the omission of a regularly used medicine 3 Around half of the medication errors that happen in hospital occur on admission or discharge 4 30% of these errors have the potential to cause harm 3,5

3. Local Examples - Medication Errors

4. Quality Improvement Specific, Measurable, Aspirational, Realistic, Time based

5. Diagnosis of Problem <Insert process undertaken e.g. -Process flow chart -Brainstorming -Ishikawa (cause and effect) diagram -Prioritising causes - Weighted voting - Pareto chart>

6. Problem Work Flow

7. Ishikawa (Cause and Effect) Diagram Insert effect Insert cause Insert group name Insert cause Insert group name Insert cause Insert group name Insert cause Insert group name Insert cause Insert group name

8. Prioritising Causes

9. Highest Scoring Causes

10. Agreed Strategies

11. Improvements

12. Lessons Learned

13. Strategies for Sustaining Improvements <Insert strategies e.g. -Real time measuring and reporting -Continual training of new staff -Ingraining as standard process -Documentation of procedure, protocols and guidelines -Encourage feedback -Continually review and refine using feedback>

14. Strategies for Spread <Insert strategies e.g. -Form unit/ward quality improvement team -Compare existing process to trial teams experience - Are there any differences requiring consideration? -Review previous teams results - Are causes similar? - Are strategies achievable? -Trial existing or adapted strategies -Measure improvements and refine if required -Communicate to next unit/ward>

15. Further Information Clinical Excellence Commission (CEC) Enhancing Project Spread and Sustainability – A Companion to the ‘Easy Guide to Clinical Practice Improvement’ www.cec.health.nsw.gov.au/programs/clinical- practice www.cec.health.nsw.gov.au/programs/clinical- practice

16. References 1.Tam V, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173:510-5. 2.Dobrzanski S, Hammond I, Khan G, Holdsworth H. The nature of hospital prescribing errors. Br J Clin Govern 2002;7:187-93. 3.Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424-9. 4.Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual 2005;20:95-8. 5.Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006;15:122-6.