medication reconciliation
TRANSCRIPT
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Med Wreck to Med Rec
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What is the problem?
Hospitalized patients who experience an adverse drug event (ADE) are twice as likely to die as those without an ADE (JAMA 1997; 277:301-306)
The Institute of Medicine has estimated that medication errors account for 7,000 deaths annually (To Error Is Human: building a safer health system, 1997, IOM)
ADEs account for 6.3% of malpractice claims (Arch Intern Med. 2002; 162:2414-2420)
Scope of the Problem – Admission
Comish, et al. Arch Intern Med. 2005;165:424-9
151 patients in a study (at least 4 prescription medications)
53 % had at least one unintended discrepancy
Omission was the most common error
38 % of the discrepancies had the potential to cause serious to moderate harm
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What Happened?
Swiss Cheese Model of Major Errors
Reason J. Human error: models and management. BMJ. 2000;320:768-770.
Transcription errorDC meds not
reviewed
Pt/care giver does not review meds
Outpt doc
unaware of
change
Sentinel Event
Admission
IOM: To Err is Human
1999- Institute of Medicine’s (IOM) report
98,000 deaths annually in hospitals
1.5 Million Potential ADEs (1/day/pt)
9000 deaths from adverse drug events
Most errors are system based, not due to reckless
individuals
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A well designed process is:
It uses a patient-centered approach
The process is easy to complete by all involved. Staff recognize the importance
It minimizes opportunity for drug interactions and therapeutic duplications by making the patient’s list of home medications available to all prescribers
It provides the patient with an up-to-date list of medications
It ensures that providers who need to have information about changes in the medication plan get that information
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Challenges
There is no clear owner of the process. There is no standardized process to ensure that the
patient’s home medication list is available to all providers and compared with the most recent list of medications as patients move through different levels of care
Physicians are reluctant to order medications that may be unfamiliar to them or that have been prescribed by others
Staff do not have the time to complete each of the steps in the process
The focus has been on completing a form rather than meeting the intent of the intervention
There are many situations in which the patient may not know or can’t provide a list of medications.
Accurate sources of information may be difficult to identify The original medication list isn’t linked to the physician
orders as the patient transitions from one location to another.
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‘One source of truth’
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PRECEDE-PROCEDE
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Adapted from: The Institute for Healthcare Improvement
The PDSA Cycle
Act
• What changes are to be made?• Next cycle?
Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)
Study• Complete the analysis of the data
•Compare data to predictions
•Summarize what was learned
Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data
Medication reconciliation program TimelineMonth 1 Month 2 Month 3
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Shadowing on UnitsKickoff & Team Orientation
Escalation PlanningLong Term Action Plan TrackingLive Metric Tracking
Plan Do Study
Activity
Progress Review # 2
Hospital Analyst TrainingSolution Tracker Updated WeeklyPrioritized Solution Implementation
Baseline Analyses Complete
Quick Win ImplementationProgress Review # 1Solution Prioritization & PlanningSolution DevelopmentRoot Cause AnalysisPain Point PrioritizationPain Point IdentificationProcess Mapping
Act/ Sustain
Initial Leadership Meetings
Baseline Establishment & Goal Setting
Prioritized Solution Approval
Solution Implementation
Issue Identification & Prioritization
Sustainability
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Nursing intervention
Education about BPMH
Education about charting in HED
Education about sources of information
Flyers
Champions
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Physician intervention
Education in doing med rec in 24 hours
High risk meds in 4 hours
On call physician to cooperate
Discrepancy clarification
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Pharmacy intervention
Educating pharmacist to make changes in HHS
Contacting outside pharmacy
Helping nurses in discrepancy
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Patient intervention
Signage in ED about bringing home meds
Wallet medication card
Education flyers in the room next to communication boards
Discharge education in regards to PCP.
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IT intervention
Glitch in system regarding indications, last dose taken etc.
Nurses access to HPF (past medical record)
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Policy intervention
Clarifying roles in policy
Addition of flow map
Addition of high risk medication rule.
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Outcome
The measurable outcomes of the program are: Increased staff and patient satisfaction. Reduced readmission rates secondary to medication
reconciliation. Increased communication with PCP at discharge. Reduced adverse drug events causing harm to the patient
secondary to prevention of medication errors. Medication reconciliation completed 100% of the time and
addressed by MD within 24 hours. Zero discrepancy in the home medication list. Nurses able to interview patient regarding the BPMH. Secondary outcomes include reduced cost, increase
quality of life, adequate refills etc.