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Transcript of Leslie Ochs PharmD, PhD, MSPH Assistant Professor UNE College of Pharmacy April 27, 2014.
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Medication Reconciliation
Leslie Ochs PharmD, PhD, MSPHAssistant ProfessorUNE College of PharmacyApril 27, 2014
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Objectives
Describe the importance of medication reconciliation for patient safety
Identify opportunities, barriers and challenges in performing successful medication reconciliation
Identify strategies for effective medication reconciliation
Describe the importance of your role in effective medication reconciliation
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Test Your Knowledge
1. What is the purpose of medication reconciliation?a. To ensure sure patient’s medications meet
current treatment guidelinesb. To decrease patient medication costsc. To reduce medication errorsd. To decrease the number of medications a
patient is currently taking
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What is Medication Reconciliation?
“The process of comparing a patient's medication orders to all of the medications that the patient has
been taking. This reconciliation is done to avoid medication errors such as omissions, duplications,
dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are
rewritten. Transitions in care include changes in setting, service, practitioner or level of care”
Best suited for inpatient services
TJC - Issue 35, January 25, 2006
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What is Medication Reconciliation?
“Reconciliation is a process of identifying the most accurate list of all medications a patient is taking – including name, dosage, frequency and route – and using this list to provide correct medications for patients anywhere within the health care system.”
Institute for Healthcare Improvement – 2007http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx
Best suited for outpatient services
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What is Medication Reconciliation?
Process of reconciling a patient’s medication list at transitions of care
Ensures patient’s medications accurate on admission to a hospital or nursing home, at inpatient transfers, on D/C and in community or outpatient setting
Helps to reduce errors Omissions, duplications, incorrect doses and
DDI Improves communication
TJC - Issue 35, January 25, 2006
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Mandates for Medication Reconciliation
2009 - National Patient Safety Goal 8
“Reconcile medications across the continuum of care” Ambulatory care Emergency and urgent
care Home care Inpatient services Long‐term care
100,000 Lives Campaign
Designed to improve care and avoid mortality
Medication reconciliation – key component
Joint Commission on Accreditation of Health Care Organizations
Institute for Healthcare Improvement
Pharmacist’s Letter 2010; Course No. 303
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Importance of Medication Reconciliation
Difficulties in process No clear roles or responsibilities▪ Duplicate in patient’s medical charts▪ Documentation in different places▪ May or may not be in agreement
Difference in collecting information▪ Consider OTC “to be medications”?
Patient’s medical condition
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Test Your Knowledge
2. What percentage of patients have unintended discrepancies on admission to healthcare facilities?a. 30%b. 25%c. 67%d. 59%
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Why is it necessary to do medication reconciliation?
Adverse Drug Events (ADEs) happen frequently 5‐40% of hospitalized patients 12‐17% of patients after discharge
Transitions increase discrepancies and the risk for ADEs 70% of patients on admission have discrepancies 1/3 of these are potentially harmful ADEs
Unintended discrepancies 67% on admission 11‐59% harmful
Mueller et al. Arch Intern Med 2012;172:1057 Kwan et al. Ann Intern Med 2013;158:397
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Types of Transitions
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How does medication information flow in these transitions?
Electronic information Written information Patient reporting Team discussion Nursing handoff
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Issues in Communication
Community Pharmacy Information• Use more than one pharmacy – not
complete• Poor communication between pharmacies• Insurance for some medication, cash for
others• Get medical information from patient or
familyLong Term Care• MD and pharmacist not on site• Assisted living may nit have medication review by
pharmacist
Discharge Instructions• Poor instructions between settings• Community Pharmacist is out of the
loop
Between MD• Direct Interaction – Hospital MD & PC MD – 3-20%• D/C summary at follow-up appt
• 1st – 12-34%• 4 week – 51-77%• Impact in care in 25%
Snow et al. J Hosp Med 2009;4:364 Hume et al. Pharmacotherapy 2012;32:e326
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Care Coordination at Discharge Pharmacist not involved in home
services Limit information sharing with home
care b/misinterpret HIPPA Discharge visits may be overwhelming Often not one entity that takes
responsibility for coordinating care. Improved with: Patient-centered medical home Accountable care organizations
Hume et al. Pharmacotherapy 2012;32:e328
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Patients at Risk for Transition Problems
Older Cognitive impairment End of life Low health literacy More than 5 medications/day Disabilities Low income Homeless New admission to long-term care
Hume et al. Pharmacotherapy 2012;32:e328
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Is there evidence that medication reconciliation programs work?
Evidence to support pharmacist’s involvement 36% of patients had medication errors on
admission – 85% originated from medication list Strategies to reduce medication errors at
transitions include pharmacist medication review at D/C
Medication review and consultation in various settings▪ Reductions in MD visits, ED visits, hospital days and
costSchnipper et al. Arch Intern Med 2006;166:565Doyle E. September 2009
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Hospital-Based Medication Reconciliation – Systematic Review
26 studies Provider
15 Pharmacist 6 Information technology 5 Other providers
Comparison Usual care
Discrepancies Intentional &
UnintentionalFeature Studies Showing
Reduction/Improvement
Medication discrepancies 17 of 17
Potential adverse drug events 5 of 6
Adverse drug events 2 of 2
Post discharge health care utilization
2 of 8
Mueller et al. Arch Intern Med 2012;172:1057
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Unintentional Discrepancies Study #1
178 pts in Boston teaching hospital
Intervention ‐ Med rec, counseling with RPh, F/U telephone within 5 days
Control - RN discharge counseling, RPH reviewed meds without formal med rec
Results
▪ 1% Intervention group had pADE
▪ 11% Control group had pADE(p=0.01)
▪ Total ADEs - No difference
Study #2 14 teams; 2 teaching hospitals in
Boston 320 pts Intervention – Web based electronic
med application – “Preadmission Medication List (PML) Builder” used to facilitate med rec process
Control – Resident took med history, RPH check order, MD wrote D/C orders, RN educated on meds
Results
2 Randomized Controlled Studies
Schnipper et al. Arch Intern Med 2006;166:565
Intervention
Control
pADEs 170 230
Admission 44 49
Discharge 126 181
Relative Reduction = 0.72Schnipper et al. Arch Intern Med 2009;169:771
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Test Your Knowledge
3. Which of he following are examples of the most common medication errors discovered by reconciling medications?a. Wrong doseb. Wrong patientc. Omission of medicationsd. Extra dose
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Medication Reconciliation as a Patient Safety Strategy
Most common errors Improper dose or quantity Omissions Prescribing errors
Less common errors Wrong dose Extra dose Wrong patient Mislabeling Wrong administration technique Wrong dosage form
TJC - Issue 35, January 25, 2006
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Medication Reconciliation as a Patient Safety Strategy
Continuation of a medication when patient no longer needs
Omission of outpatient medications on admission into the hospital
Fail to restart a medication at D/C when medication was temporarily discontinued during hospital stay
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Medication Reconciliation Process
Verification Collection of the medication history
Clarification Ensure that medications and doses are
appropriate Reconciliation
Documentation of changes in the orders
Institute for Healthcare Improvement – 2007http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx
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Prior to Medication Reconciliation
Starts prior to the visit Review list for duplicate therapies
Beta-blockers, HTN medications Remove discontinued therapies
Old antibiotic prescriptions Remind patient to bring in medications or
their list Prescription bottles best/medication list
Obtain list of medications actually filled from the pharmacy or Health Info Net
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Medication Reconciliation Process at Every Visit
Ask all patients to provide a current list of medications, including OTC and herbals
Review medication with patient Reconcile and document patient’s medication
list and EMR medication list Check new medications for interactions/conflicts
with updated EMR medication list Provide patient with a paper copy of an
updated, reconciled medication list Identify who is responsible to resolve
discrepancies and duplications
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What Medication Information Should be Collected?
Medications on the “home medication list” Prescription medications Sample medications Vitamins Nutraceuticals Over-the-counter (OTC) drugs Respiratory therapy-related medications
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What information should the medication list Include? Drug name Dose Route Strength Frequency
Indication Last dose Who is providing
the information Who is collecting
the information
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Sources for Medication
Prescriptions Over the counter medications and
supplements Family members and friends Samples Internet prescriptions Prescription assistance programs
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Test Your Knowledge
4. Which of the following are TRUE in regards to information that should be collected about a patient’s medications? a. Only include prescription and OTC products on the
medication listb. Only include those medications that the patient takes
orallyc. Herbal and nutritional supplement information is
unimportant because these products do not interact with other medications
d. The most comprehensive and accurate list is important for medication reconciliation (Rx, OTC, Vitamins, Vaccines, etc.)
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Medication History – Critical to Have a Complete List
Herbals Nutritional and dietary supplements Vitamins OTC medications Prescription medications Respiratory therapy medications
Inhalers and nebulization treatments IV solutions and medications Vaccines Radioactive medications Diagnostic and contrast agentsPharmacist’s Letter 2010; Course No. 303
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Following Medication Reconciliation Process
Determine who should be aware of the changes to the medication list
Ensure sharing discontinued medications
Failure to communicate with pharmacies leaves prescriptions active on patient profiles that can be filled by patientsDon’t forget to share the updated medication list
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What if you don’t have enough time for medication reconciliation?
Multiple chronic disease (>3) Multiple medications (>10) High risk medications
Heart medications Opioids Immunosuppressants Blood sugar medications
Medications with Narrow Therapeutic Index Anticoagulants Psychiatric medications Seizure medications
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Barriers to Medication Reconciliation
No standardized process Difficult to obtain accurate
medication history Multiple providers involved in
patient’s care MD office is is not aware of
patient’s prescriptions
ASHP-APHA Medication Management in Care Transitions Best Practices 2013
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Challenges to Medication Reconciliation
Understand the importance Obtaining complete and accurate
information Engage everyone in the process
Health care providers, patients and caregivers Create an expectation of the patient that
they receive a current medication list Develop patient responsibility to carry the
list Time to reconcile medications
Resources need to complete reconciled listASHP-APHA Medication Management in Care Transitions Best Practices 2013
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Strategies for Medication Reconciliation
Review the workflow process and see how medication reconciliation can best be incorporated within the facility
Clearly define responsibilities Remind patients to bring medication bottles List printed at check-in, patient to review
while waiting for their appointment Quality audits and feedback on
performance/program
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What features do successful medication reconciliation programs share?
Multidisciplinary Team Transitions involve many people - must involve a variety of providers Providers must communicate and collaborate well ‐ avoid turf issues and
silo approach Institutional Support CQI central to process - helps document positive outcomes Dynamic Pharmacy Team
Changing Roles▪ Reassessment of job responsibility▪ Support for pharmacist in expanded role
Pharmacy extenders can be very useful - pharmacy interns, residents, technicians
Training for pharmacy team▪ Reconciliation, prior authorization, documentation, communication, and
data management▪ Competencies & protocols to ensure high standards▪ Schools have focused on this in APPEs
ASHP-APHA Medication Management in Care Transitions Best Practices 2013Mueller et al. Arch Intern Med 2012:1067
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What features do successful medication reconciliation programs share?
Metrics to show Return on Investment (ROI)
Types of metrics Readmit ED visits Med Rec problems Disease specific metrics Patient satisfaction Always plan goals and
data collection before program
Efficient transfer of information
Approaches for transferring information: EMR Prior authorization E-prescribing Contacting
provider/prescriber Billing options
Data to Justify Program
Share Information Well
ASHP-APHA Medication Management in Care Transitions Best Practices 2013
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What does a “best practice” medication reconciliation program look like?
Best possible medication history (BPMH) Structured interview to identify all prescribed and
OTC medications AND Verify the results with at least 1 other reliable
source ofinformation▪ Medication vials▪ Patient medication lists▪ Community pharmacy record▪ Clinic record
Medication reconciliation BPMH AND Correct discrepancies
Kwan et al. Ann Intern Med 2013;158:397
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What steps should be followed in creating a medication reconciliation program?
Make a standard form or guide to help carry out the process
Make sure the approach facilitates getting a complete list of
medications/treatments Dose, route, frequency, immunizations, allergies, herbals, etc
Put med list where it is easy to find Determine a timeframe for completion Assign responsible person at all transitions (e.g., admit,
discharge) Give patient a discharge med list Suggest patient carry discharge list and update Start with a small sample to pilot the process Provide education to all health care providers participating
in medication reconciliation Give feedback on program to providers
Pharmacist’s Letter 2010; Course No. 303
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Community Pharmacist Role
Important component of medication reconciliation Communication with pharmacy to obtain accurate
medication history on admission▪ Important to reducing medication errors
Communication with patients after discharge▪ Counsel medications▪ Remind to stop taking unnecessary pre-admission
regimens▪ Answer questions▪ Medication record▪ Update information
Pharmacist’s Letter 2010; Course No. 303
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Community Pharmacist Role Educate patients and family members to
serve as advocates Patients understand the complexities of the
medication process and the role they play in medication management
Allows patients to keep better track of medications they are taking
Have patients bring their medications to every healthcare encounter
Educate and empower patients to be responsible for their medication list
Pharmacist’s Letter 2010; Course No. 303
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Medication Reconciliation Resources
The Institute for Healthcare Improvement (www.ihi.org) Case studies, literature review, resources, frequently
asked questions The Massachusetts Coalition for the Prevention of Medical
Errors (www.macoalition.org ) Safe practices, sample processes, toolkit, reference list
The Joint Commission (www.jointcommission.org ) Information on compliance with standards, frequently
asked questions, flow chart The American Society of Health‐System Pharmacists (
www.ashp.org) “how to guide, reference list, “clearing house information”
The Agency for Healthcare Research and Quality (www.ahrq.gov) Toolkit
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Medication Form Example
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Questions?
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Post Question 1
1. All of the following are outcomes of an effective medication reconciliation process except:a. Promote overall continuity of patient careb. Increase in medication errorsc. Support safe medication use by patientsd. Encourage providers and health systems to
collaborate
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Post Question 2
2. The important steps of an effective medication reconciliation as suggested by the Institute of Healthcare Improvement (IHI) include:a. Verificationb. Clarificationc. Reconciliationd. All of the above
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Post Question 3
3. What information should a community pharmacist share when contacted by other healthcare providers to help update a patient’s medication list?a. Drug name, dose, route and strengthb. Medication frequencyc. Last refill or date receivedd. Healthcare provider who is collecting
medication informatione. All of the above
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References
1. http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx2. Joint Commission on Accreditation of Health Care Organizations Sentinel Event Alert. Using
medication reconciliation to prevent errors. Issue, January 25, 2006. www.jointcommisson.org/sentinel_event_alert_issue_35_using_medication_reconciliation (Accessed April 15, 2014).
3. Improving Patient Safety: medication reconciliation basics. Pharmacist’s Letter 2010; Course No. 303
4. Mueller SK, Sponster KC, Kripalani et al. Hospital-based medication reconciliation practices: systematic review. Arch Intern Med 2012;172:1057
5. Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397
6. Snow V, Beck D, Budnitz et al. Transitions of Care Consensus policy statement. J Hosp Med 2009;4:364
7. Hume AL, Kirwin JL, Bieber HL et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy 2012;32:e326
8. Doyle E. Medication reconciliation done right. September 2009. www.todayshospitalist.com/index.php?b=articles_read&cnt=871 (Accessed April 15, 2014).
9. Schnipper JL, Kirwin JL, Cotungo et al. Role of pharmacist counseling in preventing adverse events after hospitalization. Arch Intern Med 2006;166:565
10. Schnipper JL, Hamann C, Ndumele CD et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events. Arch Intern Med 2009;169:771
11. ASHP-APHA Medication Management in Care Transitions Best Practices 2013