Implementing Medication Reconciliation in Long-Term Care O’Connell Date: April 14, 2008 by Bonnie...

Implementing Medication Reconciliation

in Long-Term Care O’Connell

Date: April 14, 2008by Bonnie Walker

Risk Manager /Patient Safety Advisor

Safer Health Care Now!• National Canadian Patient Safety Campaign! • National Steering Committee - Canadian Patient Safety

Institute (CPSI)• Purpose:to help teams,hospitals develop skills/capacity

to make quality improvements and monitor their performance

• Provide ideas, supports and resources to hospital teams across the country with the goal of providing safer care.

• Focus is harm reduction and improving care processes and outcomes for patients, families and caregivers

Canadian Adverse Events Study• 7.5% of all hospital admissions are associated

with an adverse event (2000)• 36.9% of which were deemed preventable• Translates to 70,000 preventable adverse

events per year• Contributing to between 9,000 and 24,000

preventable deaths in Canada (2000)Adverse Events in Canadian Hospitals (Baker, R. & Norton, P. et al (2004))

The Evidence• Many patients (37% on average) had drug omissions at

admission.Cohen J, Wilson C, Ward F. Pharmacy in Practice 1998;13-6.

• Many patients (70%) not receiving medication instructions at discharge.

Alibhal SMH, Han RK, Naglie G. J Gen Intern Med 1999;14:610-616.

• Medication histories are often incorrect or complete:

- 25% of Rx. Medications not listed

- 61% of patients have 1+ med not listedLau HS et al. Br J Clin Pharmacol 2000; 49:597-603.

The Evidence

• Chart reviews have revealed that over half of all hospital medication errors occur at the interfaces of care

Rozich et al., J. Clin Outcomes Manage. 2001; 8(10):27-34)J Clin Outcomes Manage 2001;8:27-34

• Implementation of medication reconciliation along with other interventions decreased the rate of medication errors by 70% and adverse drug events by 15%, over a seven month period.

Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care 2004;13(1):53-59

The Evidence• A successful medication reconciling process reduces

work and rework

- reduced nursing time at admission by over 20 minutes per patient

- reduced pharmacists time at discharge by over 40 minutes

Rozich,JD, Howard RJ,Justeson JM, Macken PD, Lindsay ME,Resar RK. J Quality Saf. 2004: 30(1):5-14

SHN Improvement Initiatives:– Medication Reconciliation– Acute Myocardial Infarction (AMI)– Surgical Site Infection (SSI)– Rapid Response (RRT)– Central Line Infection– Ventilator Associated Pneumonia (VAP)– Falls LTC– MRSA– DVT

Medication Reconciliation As of March 2008:

240 healthcare organizations and 885

teams enrolled nationwide (325 Med Rec Teams)

26 districts / organizations enrolled from Atlantic Canada

Medication Reconciliation • Goals:

– The primary goal of medication reconciliation in long-term care is to eliminate undocumented intentional discrepancies (documentation errors) and unintentional discrepancies (medication errors:omissions, additions etc.) by reconciling all medications, at all interfaces of care, for all residents.

– Improve the process of obtaining, updating and communicating a complete Best Possible Medication History (BPMH)

• The primary emphasis is to create systems of care that dramatically reduce the number of Adverse Drug Events through the reconciliation of medications.

Medication Reconciliation Measures of Success

1. # of undocumented intentional discrepancies (documentation accuracy).

2. # of unintentional discrepancies (medication error).

3. % of residents that are reconciled.

What is Medication Reconciliation?• A process in which medications are compared at

interfaces of care: Admission Transfer Discharge

• Discrepancies are identified and reconciled with physician

• Intervention minimizes patient harm from unintended discrepancies

ISMP Canada 2005

What is Medication Reconciliation?

• “a formal process of obtaining a complete and accurate list of each patient’s current home medications-including name, dosage, frequency and route- and comparing the physician’s admission, transfer, and/or discharge orders to that list. Discrepancies are brought to the attention of the prescriber and, if appropriate, changes are made to the orders. Any resulting changes are documented.”

ISMP Canada 2005

What’s a BPMH?(Best Possible Medication History)

• Documentation of all medications that a resident has been taking previously including drug name, dose, frequency and route.

Obtaining BPMH • Community pharmacy• Review medication lists, MARs, vials• Interview resident and /or family• Consult notes from referring physician• H&P

Obtaining BPMH • Nursing/pharmacist (referral) to collect

information at admission• Physician-as a reference and/or order when

writing initial orders for medications• Physicians/nurses/pharmacists throughout the

resident’s stay as a reference

• Virtually all hospitals who have successfully addressed admission medication reconciliation have created a special form as part of the solution!

Western Regional Integrated Health Authority For O’Connell LTC / DVA Unit Use Only!

MEDICATION HISTORY ADMISSION MEDICATION ORDERS

**Keep this form with the Physician Orders**

Site: O’Connell LTC O’Connell DVA Patient Label/Addressograph

This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for pre-admission medications. New medication prescribed on admission should be written on the physician’s order sheet.

Source of Medication Information (Check ALL that apply) Review of patient/resident medication list Review of medication vials Review previous hospital records Family Physician list Patient/resident recall Family/caregiver recall

MA MAR from another facility Other:__________________ Community pharmacy list Pharmacy Name:______________________

Diagnosis: (check all that apply) □ IHD □ PVD □ CRF □ R.Arthritis □ Epilepsy □ AFiB □ CVA □ ARF □ O.Arthritis □ Anxiety □ CHF □ HTN □ COPD □ NIDDM □ Depression □ Dyslipidemia □ MS □ IDDM □ Other:

Weight: kg Allergies: Height: cm

Best Possible Medication History (BPMH): Include regular and PRN medication taken at previous care setting

Physician Admission Orders: To complete upon admission

Medication Name & Strength (List all prescriptions and regularly taken OTC & PRN medications prior to admission).

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Reason for Change/Hold/Discontinuation

BPMH obtained by: __ Date/Time: __________ BPMH obtained by: _________Date/Time: __________

Prescribing Physician: Date/Time: _________ Prescribing Physician: Date/Time: _________

Additional Medications Identified After BPMH Taken ( Please Fax Additions to Pharmacy.)

Orders for additional Medications, identified after initial BPMH completed, to be written on Routine Physician Order pink sheet. Additions to BPMH obtained by: Date/Time: _________________________________________

NOTE: all addition preadmission medications received after the initial BPMH has been completed must have those orders written on the routine Physician Orders sheet.

Please fully complete additional forms, if additional space is needed to accommodate number of medications Risk Score : (see tool form # ) Pharmacy Consult Recommended No Yes Reason for Referral: NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not. Disposition of Patient’s Medication on Admission: Locked up in nursing unit Brought to hospital. Sent home with: Not brought to hospital Original Copy – On Chart Copy – to Pharmacy Fax to Pharmacy: Pages(s) of . Form #

Completing the Medication History / Admission Orders form!

Western Regional Integrated Health Authority For O’Connell LTC / DVA Unit Use Only!

MEDICATION HISTORY ADMISSION MEDICATION ORDERS











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Include all sources required to thoroughly complete the BPMH.

Include history of illnesses.

Note height and weight and known allergies.

Continue to Complete by:Western Regional Integrated Health Authority

For O’Connell LTC / DVA Unit Use Only! MEDICATION HISTORY

ADMISSION MEDICATION ORDERS











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List name, dose, route, frequency for each medication.

Signature,date and time when BPMH is completed. To be done within 24 hrs.

Obtain physicians intention to continue, change, discontinue or hold. Obtain reason.

• Continue to Complete by:Western Regional Integrated Health Authority













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Obtain physician admission orders for pre admission medications.

Indicate risk score for pharmacy referral.

Indicate disposition of residents medications.

• Continue to Complete by:Western Regional Integrated Health Authority













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Note additional pre-admission medications identified after 24 hrs here.

Sign, date and time additional medications noted.

Ensure orders for additional medications are noted on routine Physician Order pink sheet.

• Complete Risk Score: Western Regional Integrated Health Authority For LTC O’Connell / DVA Unit Use Only! Risk Score /Pharmacy Referral **Keep this form with the Physician Orders**

Patient Label/Addressograph

Patient / Resident Medication Risk Assessment Tool

(circle all applicable factors)

0 – 64 years

0

65 – 80 years

1

Age

>80 years

2

0 - 1

0

2 - 4

2

5 - 7

3

Number of Medications

Prior to Admission

8 or more

6

Antiseizure

3

Anticoagulant

3

More than two cardiovascular medications.

5

High Risk Medications

Prior to Admission

Diabetic Medications (oral+/- insulin)

2

Has the patient been transferred from ALC unit?

Automatic Referral to Pharmacy

Is the reason for admission clearly drug-related (e.g. drug toxicity, non-compliance, polypharmacy)?

Automatic Referral to Pharmacy

Total Score

Examples of medications for each medication category: Antiseizure: e.g. carbamazepine, phenytoin, valproic acid & divalproex sodium. Anticoagulants: e.g. warafin, low molecular weight heparin (e.g. tinzaparin, dalteparin, enoxaparin), heparin. Not ASA. Cardiovascular Medications: e.g. blood pressure meds, cholesterol meds, digoxin, amiodarone, daily ASA, clopidogrel, diuretics. Do not count anticoagulants as a cardiovascular medication. If total score is > or = to 10, referral to Pharmacist is recommended.

Original (white) – Patient’s / Resident’s Chart Faxed copy - In-hospital Pharmacy NOTE: Always ( whether high or low score) fax the completed Risk Score tool to Pharmacy.

Form #

Score all categories and add final risk score.

Fax all completed risk scores to Pharmacy!

Include:• Current home medications including dose,route and

frequency• Medications ordered at admission• Continue,start, stop• Time of last dose• Source of the information• Assessment of patient compliance• OTC’S and herbals (organization decision)

Medication History Taking


Interview:• Encourage questions from the resident / patient• Encourage bringing medications and use of

medication wallet card or home list• Prompt regarding non-pill dosage forms and PRNs

– Creams, drops, inhalers, spray, samples


Interview: • Balance open-ended questions with yes/no questions• Nonbiased questions• No leading questions• Vague responses may indicated non-adherence• Avoid medical jargon

Medication History TakingInterview Questions:

• Do you have any allergies to medication? Describe the reaction.

• What medication were you taking prior to admission? • Did a doctor change the dose or stop any of your

medication recently?• Have you changed the dose or stopped any of your

medication recently?• Have you recently started any medications?


Interview Questions:

• Have any of your medications been causing side effects?• When you feel better, do you sometimes stop taking your

medication?• Sometimes if you feel worse when you take your

medication, do you stop taking it?• Are the pills in the bottle the same as what is on the label?• Have you changed your daily routine to accommodate

your medication schedule?

Discrepancies Identified

Admission Medication Orders

(AMOs)

Best Possible Medication History

(BPMH)

Intentional Discrepancy

No

Ask prescriber if intentional?

Documented in chart or obvious due to patient’s

clinical condition?

Ensure medication reconciliation at Transfer and Discharge. See Chapters 3 & 4 in GSK

IMPROVE WITH:Standardized Admission Documentation

No

Document

Reconcile(correct)

No further action required at admission

IMPROVE WITH:Standardized Admission Documentation

Medication Reconciliation Process Flow Map Admission to Healthcare Facility

Yes

Yes, Intentional discrepancy

Yes

No

Compare

IMPROVE WITH:Better training in

medication historyPatient awareness

Backup process for complicated patients

– pharmacist-conducted history Source: SHN

Medication Reconciliation Getting Started Kit (2007)

Why Medication Reconciliation? • Medication reconciliation fits with culture of safety

and optimal patient / resident care• Medication reconciliation evidence has shown

reduced medication discrepancies• Medication reconciliation will save time for nurses,

physicians, and pharmacists• Already take a medication history: now we are doing

it on one form and it will be easier to find

Why Medication Reconciliation? • Will know that a medication change is intentional (rather

than wonder if there was a transcription error or a missed order), and be able to advise the patient / resident and family members accordingly

• It will be easy to find the at-home medication list in order to reconcile on transfer / discharge as all preadmission medications will be on the new admission form

• Outcomes from the changes with medication reconciliation are being monitored for improvements

Questions

Implementing Medication Reconciliation in Long-Term Care O’Connell Date: April 14, 2008 by Bonnie...

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