Medication Reconciliation:whose job is it anyway?

Why a Multidisciplinary approach?

Limitations identified in ‘pharmacists only’ approach•Baseline data from June 2010 showed pharmacists could reconcile medications for 35% of patients within 48 hours (gold standard is within 24 hours)•Insufficient pharmacists to complete and sustain medRec •If pharmacist’s sole focus could compromise other medication safety activities.•Gaps in medRec process would occur after hours and weekends•Address by targeted intervention of complex patients only?

Initial Training: January 2011

• Pharmacy High 5 team developed a presentation– Presented to pharmacists and High 5 core group:

• “Train the trainer”• Best Possible Medication history taking• Med Rec process • Compulsory attendance • Resources provided to train/teach ward staff.

– Training Road shows – ward based training• Identified unit-specific processes

– Grand/ ICU rounds

Ongoing Training

• JMO, Registrar and Resident training– Occasional ward based training– Secured additional training slots in orientation

program• Medical Intern Pre-registration workshop

• Pharmacist orientation

• New grad nursing awareness training

Patient Safety Culture in our hospital

2014 Survey:

Objectives:Primary: Do clinicians understand the importance of Medication Reconciliation: who, how and why?Secondary:

– Were there any barriers to implementing this change

– Can these barriers be overcome or resolved?

Question Design

Method

• 2 Study sites: POWH, Redlands• Study group: Doctors, pharmacists and nurses• Collected data for 7 days via

– Paper forms– Email ‘Survey monkey’ link

• Supported by Directors of Clinical Services/Nursing/Pharmacy

• Survey respondents remained Anonymous

Results: DemographicsStaff position Approx. Staff

PopulationPopulation that responded (%) n = 138

Doctors (JMOs & SMOs)

400 49 (12%)

Nursing 1200 65 (5%)

Pharmacists 32 24 (75%)

Results: Education/Training

• Sample Comments/suggestions:– “I thought this was the role of the pharmacist? Any training would be

useful” (Intern)– “Wasn’t able to attend” (Registrar)– “Online training, inservice, verbal discussion?” (RN)

Answer Yes No

Did you receive any education/training?

N = 133 (%)

62 (46.6) 71 (53.4)

Was the education given at orientation sufficient?

N= 106 (%)

58 (54.7) 48 (45.3)

Who is responsible for completing the Medication Management Plan (MMP) form?

What do you understand to be the main reason/s for Medication Reconciliation?

Safety Culture

*Medication Management Plan Form = a tool used at POWH to conduct Medication Reconciliation

Overall CommentsClinician Comments

Doctor MMPs are very useful for JMOs!A good tool when available in patient notesIt’s a great initiative, please keep it goingElectronic would be greatMMP has no significant impact on admission because it is not usually done on admission

Nurse I have found the MMP helpful if I have difficulty reading the doctor’s handwriting and also for checking that doses are correct when the charts change over to the next oneSome education would be good so we can use it more effectively on ward roundsIt’s not the nurse’s role to fill out the MMP form-should be medical or pharmacist

Pharmacist MMPs are very useful but time consumingOnly Pharmacists are doing MMPsIncreases workload for pharmacists

Discussion

• Identified barriers:– Education reaching all stakeholders (frontline up)– Time– Documentation (electronic vs paper)

• Identified improvements:– Patient safety culture awareness– Multidisciplinary approach identified

• Limitations

Factors identified required for future success

• Dedicated resources• Strong multidisciplinary leadership• Physician champion engagement • Software that supports the High 5 SOP

and• Ongoing comprehensive staff education

plan• Change readiness of organisation

A Doctor’s perspective

Doctors’ attitudes

• ‘We’re very busy’

• ‘Can’t the pharmacists do it?’

• ‘It means writing everything out multiple times’

• ‘What’s the point of it?’

• ‘Why don’t we just wait until electronic prescribing

comes in?’

Issues

• Capturing the correct audience to educate them that its everyones

responsibility

• We are missing the middle level (staff specialists, VMOs etc)

• IT systems don’t speak to each other (or a mixture of paper and

electronic notes)

• It requires a change in attitude- but support for change

• Senior staff don’t realise the importance of the process

Problem:•Professional boundaries and established hierarchies may result in disagreements about where the responsibility for medicines reconciliation lies

Solution:•Focus on reducing the risk for patients and increasing the availability of timely, accurate information •Any potential professional or hierarchical differences should be put aside to enable appropriately trained and competent healthcare professionals to take the lead

Problem:•Competing demands and the common response that the �problem is too big ‘we dont know where to start’ can be � � �overwhelming for staff•This can lead to delays in getting medicines reconciliation off the ground

Solution:•People need to be supported by managers to enable them to prioritise their workload•simple structures should be put in place so that medicines reconciliation becomes part of the organisation’s everyday work�

There are no quick fixes, but this is a far from insurmountable problem

A possible five-level hierarchy approach:

• There are no shortcuts to breaking down silos.

• You can’t fix the environment if the organization doesn’t

understand the problem.

• You can’t improve the development process if the right

environment doesn’t exist to enable healthy guidelines.

• Climb the pyramid brick by brick to the ultimate goal: better

clinical outcomes through true collaboration.

Practicalities

• How do we ensure senior physicians care?

• IIMS categorised into ‘med rec’ errors?• Statistics on IIMS, Med rec compliance to individual

departments/teams? League tables??

• Grand rounds?

• Presentations of RCAs concerning medication errors?

• Using Accreditation- Standard 4 as a bargaining chip?

Involving Patients

•The value of involving patients and/or their carers in the medicines reconciliation process should not be underestimated

•Patients are a valuable source of information about the medicines they take and, with support, they can be encouraged and enabled to take a fuller and more active part in the process

Organisational approach

• The profile of medicines reconciliation needs to be raised in all healthcare organisations

• The Chief Executive, senior management lead and board members of an organisation can help by promoting the uptake of medicines reconciliation

• Collaborative approach with other Australian hospitals involved

• Get process right before instituting eMM- detrimental to put bad stuff into a good system

Guess what?Its YOUR job!

Acknowledgements

• Survey question design & data collection: Ketty Rivas (Safety and Health Outcomes Officer) , Selina Boughton (Pharmacist)

• Survey promotion: POWH Pharmacists