Lessons from the High 5s Project Margaret Duguid Former Pharmaceutical Advisor Helen Stark Senior...

Lessons from the High 5s Project Margaret Duguid Former Pharmaceutical Advisor Helen Stark Senior Project Officer 14 November 2014

Overview Background and goals Project methodology Lessons learned Australian results National Safety and Quality Standard 4 Medication Safety

WHO High 5s Project Established by WHO in 2007 International collaborative WHO, Joint Commission International and 9 countries Australia, Canada, Germany, France, The Netherlands, Singapore, Trinidad & Tobago, UK, USA Funded WHO, AHRQ, Commonwealth Fund 5 year project

WHO High 5s Project Aim Determine feasibility of implementing Standard Operating Protocols (SOPs) in no. countries, healthcare environments Assess impact on patient safety Slide 1 of 14

WHO High 5s Project Standard Operating Protocols (SOPs) 1.Correct procedure at correct body site 2.Medication accuracy at transitions of care (medication reconciliation) 3.Concentrated injectable medicines

www.ismp-canada.org/medrec/

Project oversight Internationally High 5s Steering Group Face to face meetings 2 x year Monthly teleconferences High 5s website E- bulletin for High 5s hospitals Webinars International hospital meeting Nationally Medication Continuity Expert Advisory Group

Medication reconciliation SOP

Medication errors at transfer of care the problem Admission Discharge Admission Histories 10 -67% contain errors 1 Up 1/3 errors PADE 2 Medication orders 30 70% patients had discrepancies Between history and admission orders 3 Internal transfer 62% patients had 1 unintentional discrepancy 36% PADE 4 Discharge orders 41% patients had 1 discrepancy 23% omissions 5 Readmission 2.3 x more likely if 1 med omitted 6 1. Tam VC, Knowles SR et al, CMAJ 2005 2. Cornish PL, Knowles SR, Archives Int Med 2005 3NICE NPSA Tech Bulletin medication reconciliation 2007. 4. Lee J et al Annals Pharmacotherapy 2010 5.Wong J et al Annals Pharmaco 2009 6.Stowasser, J Pharm Pract Res 2002 1

Medication reconciliation the solution Formalised medication reconciliation at admission, transfer and discharge reduces medication discrepancies (errors) by 50 94% 1-4 1.Vira T, Colquhoun M,et al. Qual Saf Health Care 2006;15:122-6. 2.Pronovost P, Weast B, et al. J Crit Care 2003;18:201-5. 3.Santell JP. Jt Comm J Qual Patient Saf 2006;32:225-9. 4.Rozich JD, Resar RK. J Clin Outcomes Manage 2001;8:27-34

Medication reconciliation Medication reconciliation is the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care.

Medication reconciliation SOP Formal, structured process Staff trained Multidisciplinary Doctors, nurses, pharmacists, pharmacy technicians Partnership with patients, families, carers Integrated into existing processes of care Within 24 hours of admission Phase 1 On admission for patients 65 years of age admitted through emergency department to a hospital ward

Medication reconciliation process Step 1 Obtain a best possible medication history (BPMH) Step 2 Confirm the accuracy of the history Step 3 Reconcile the BPMH with prescribed medicines Step 4 Supply accurate medicines information

Interview patients and/or carers ( if possible) Systematic approach Compile an accurate and comprehensive list Current medicines patient taking prescription, OTC, complementary medicines Recent changes, medicines ceased Step 1 Obtain a best possible medication history (BPMH)

Verify with one or more sources Carer or family Medicine containers (including blister packs) Medicines lists (patients) GP lists, records Community pharmacy records Electronic/paper health records, discharge records Medication charts from other facilities e.g. nursing home Confirm accuracy of history Step 2

Document in one place in patient record Use to : Document BPMH Document sources of information Reconcile history with prescribed medicines. Document issues, discrepancies and actions. Keep with NIMC for easy access One source of truth

Compare with medicines ordered Resolve discrepancies with prescriber, document changes Step 3 Reconcile BPMH with prescribed medicines

The person taking over the patients care is supplied with an accurate and complete (reconciled) list of the patients medicines and explanation of any changes. Internal transfer of care (e.g ICU transfers) Discharge Care provider Patient and carer Step 4 Supply accurate medicines information

Project methodology 1.Complete AHRQ patient safety culture survey 2.Implement Medication Reconciliation SOP Using QI methodology 3.Evaluation plan Implementation experience survey (6 monthly) Performance measures Rate and quality of medication reconciliation Analysis of SOP related adverse events In-depth interviews with 3 sites 5 sites in Australia

21 Project implementation in Australia Commenced January 2010 - 18 health services 2 x 2 day workshops 2010 2 x 1 day workshops in 2011 Video conference 2013 Teleconferences - monthly then 2nd monthly Webinars, email newsletter All materials posted on High 5s website Support from senior project officer

High 5s workshop 2011 Poster award winners High 5s hospitals workshop Peoples choice

Implementation resources

25 Medication reconciliation resources... Medication management plan + implementation resources MATCH UP Medicines Resources www.safetyandquality.gov.au

Medication reconciliation resources Get it right. Taking a best possible medication history 1. Video CD and You tube channel www. Safteyandquality.gov.au 2.Online learning module http://learn.nps.org.au/

27 AUSTRALIA: Australian Commission on Safety and Quality in Healthcare Improving quality and timeliness of information on admission Bring medicines with patient Patients medicines lists Engaging with consumers Mistakes can happen with your medicines How to prevent them Have a medicines list

Implementation Strategy Oversight of implementation Project work plan Risk assessment of proposed process Pilot testing Spread methodology Communication plan Evaluation Strategy Maintenance and improvement

Reasons for withdrawal 6 Australian health services withdrew Change in priorities 2 Lack of resources for evaluation, independent observer2 Lack of resources for MR process, evaluation1 Concern re MR taking focus away from medication review1 Lack of perceived benefit1

Lessons (International) Full implementation was challenging Reliant on pharmacists for success Additional pharmacists needed for: More timely BPMH, medication reconciliation Coverage for after hours, weekends and holidays Coverage of new areas, wards units Performance measurement essential

Lessons Challenges and barriers Barriers and challenges to SOP implementation Lack of resources - Training materials, medication reconciliation form Lack of human resources for: Med Recon Data collection Ongoing training Competing priorities Considered Pharmacy Business Lack of buy in by: Organisational leadership Senior staf f Lack of Technology to support Med Recon

Lessons Benefits of SOP Reported benefits of the SOP Positive impact on: Related activities Patient care Reduced medication discrepancies and potential ADEs Measurement data used for business case to gain additional pharmacist resources Improved communication between hospitals and community care providers Improved multidisciplinary teamwork Improved documentaton

Drivers for SOP implementation National guidelines and standards Accreditation requirements Access to community dispensing data Pharmacy technicians

What makes for effective and sustainable medication reconciliation? Recognition as a patient safety priority Senior leadership support from the health service executive and senior clinicians Interested and influential clinical champion(s) Resources to conduct medication reconciliation and measure improvement

Effective and sustainable medication reconciliation (contd) Ongoing training of clinical staff Policies and procedures on medication reconciliation Integration of Med Rec into existing work flows, electronic health records and clinical information systems.

Further information on High 5s project http://www.who.int/patientsafety/implementation/solutions/high5s/High5_InterimReport.pdf?ua=1

NSQHS STANDARD 4 MEDICATION SAFETY

Medication Safety Standard

High 5s Project Resources

Medication safety standard

Australian Project Results Margaret Duguid Pharmaceutical Advisor Helen Stark Senior Project Officer

Importance of measurement Evaluation Strategy Evaluation Results Resources

Tam VC, Knowles SR, Cornish PL et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ, 2005; 173:510-515 The Problem

Recent Australian paper 1 Multi-centre, prospective observational study in 8 EDs Patients taking more than one medicine and a GP referral letter (median 6) GP referral letters compared with BPMH taken by ED pharmacist n=414 patients 1. Taylor S et al, Australian Family Physician Vol. 43, No. 10 Oct 2014

The Problem 87.2% patients had one or more discrepancies between BPMH and GP referral letter Median no. of discrepancies was 3 Most common: omission of regular medicine or inclusion of a medicine patient no longer taking 62.1% of patients had one or more discrepancies of moderate or high significance

Multi-component evaluation strategy Measurement an integral component of the SOP 1.Performance measures 2.SOP implementation experience 3.Event Analysis

1. Performance Measures Four years of data (June 2010 to June 2014) Four measures (MR1 4) 10 hospitals contributing, staggered implementation Project level results show significant variation from hospital to hospital and country to country Present Australian data only

MR1: Percent of patients reconciled within 24 hours of decision to admit Purpose: Measure hospitals capacity to reach as many eligible patients as possible Creation of BPMH, identification of discrepancies & communication to prescriber within 24 hours Method: Eligible patients: 65 years and over admitted through ED to inpatient services All eligible patients or random sample of 50 using approved sampling method Monthly data collection Entry into High 5s secure website, approved by Commission Goal: 100%

MR1: Percent of patients reconciled within 24 hours of decision to admit MR1 ranged from 41.8% to 59.4% across participating hospitals with an average of around 50.4% Trend line stable Key finding: Reconciliation within 24 hours regarded as ideal for patient safety but difficult to achieve for majority of hospitals

MR1: Percent of patients reconciled within 24 hours of admission

Quality measures: MR 2,3,4 Purpose: To verify quality of medication reconciliation process Use independent observer to pick up outstanding medication discrepancies Intentional vs unintentional, documented vs undocumented Method: Chart audit (n=30) from sample of 50 taken for MR1 Prospective or retrospective Monthly then quarterly or six monthly if stable Data verification & entry into High 5s website Goal: Aim to reduce to a minimum MR3 target of less than 0.3 per patient MR4 no target specified

Measure Description MR-2 Mean number of outstanding undocumented intentional medication discrepancies per patient MR-3 Mean number of outstanding unintentional medication discrepancies per patient MR-4 Percentage of patients with at least one outstanding unintentional discrepancy Quality measures: MR 2,3,4 Measuring accuracy of the medication reconciliation process Discrepancies that have slipped through the cracks MR2 example: betablocker stopped by surgeon before surgery but not documented anywhere MR3 example: omission, commission, wrong medication, strength, dose or form

MR2 mean undocumented intentional discrepancies per patient Prescriber made an intentional choice to add, change or discontinue a medication but decision not clearly documented Creates confusion, additional work and could lead to ADEs

MR3 mean outstanding unintentional discrepancies per patient Where med rec is conducted, hospitals achieved target of less than of 0.3 outstanding unintentional medication discrepancies per patient, with trend towards zero over time for several hospitals

MR4 percent of patients with at least one outstanding unintentional discrepancy

Limitations of MR1 - 4 Small sample size for MR 2 4 Only review med recs done within 24 hours Definitional issues what to include as a discrepancy/MR2 vs MR3 Inter-rater reliability issues Prospective vs retrospective data collection Herbal medicines should be documented on BPMH however omission considered to be intentional and discrepancy not counted eg., MO didnt order Ginseng but not documented OTC medicines should be treated same as prescription meds because prescriber needs to make decision about continuation or non continuation eg aspirin

2. Implementation Experience Surveys All hospitals completed survey every 6 months Annual interviews conducted in 5 hospitals Provided additional insight on hospitals experience

Reported benefits from SOP Reduction in medication discrepancies and potential medication errors Standardisation of med rec processes across the hospital Spreading from admission to discharge and improved business processes at discharge Embedding process into hospital work flow and routine data collections - strong framework for hospitals to meet relevant criteria in the Medication Safety Standard 4

Reported benefits from SOP Improved teamwork & recognition of importance of med rec among non-pharmacist clinicians and senior mgt Improved communication with community health care providers and patients Opportunity to participate in international patient safety project and associated benefits of sharing lessons learned nationally and internationally Access to Commission training materials and resources Using High 5s data to obtain additional pharmacy staff for medication reconciliation after hours/weekends

Reported benefits from SOP Multi-facetted High 5s evaluation strategy provided hospitals with in-depth understanding of the medication reconciliation service Performance measures useful for: Tracking improvement, providing feedback to staff, mgt Identifying gaps in practice, training requirements Developing business case for resources MR 1 and MR3 - most useful Majority will continue to evaluate med rec with some moving focus to discharge Med rec now part of usual care

The High 5s project has engendered pharmacists and medical staff with a greater understanding of the value of preventing adverse consequences from medication discrepancies and clear documentation of their intentions. Although we believed that we already performed medication reconciliation to a high standard, the audit process has allowed us to become more consistent across our service (metropolitan hospital)

Challenges staff resources /staff resistance No. patients receiving medication reconciliation is closely tied to available clinical pharmacist resources Medical and nursing staff often report not their job Some nursing staff feel they lack the necessary pharmaceutical knowledge to perform this task Hospitals report some improvement in teamwork over project Real change requires education at under graduate level Not my job!

Challenges lack of staff No. of clinical pharmacists varies markedly by hospital and sector Private hospitals - less clinical pharmacists resulting in lower rates and reduced ability to spread med rec across the organisation Education of large numbers of staff required significant initial and ongoing commitment & resourcing (under estimated upfront) Hospitals were required to re-allocate clinical pharmacy staff from other tasks to conduct med rec and/or for project evaluation and education

How many hours per week does the hospital provide a medication reconciliation service?

Challenges lack of electronic systems Lack of integration of med rec (paper) with eMM systems Some sites had a new eMM system in ED introd. during project Medication reconciliation is conducted in all inpatient areas. Improving timely rates of medication reconciliation on all eligible patients within 24 hours will only be possible when electronic documentation of medication reconciliation is available and this tool can interact with current medicine management systems. (large metropolitan teaching hospital)

Future Plans Plans to implement electronic systems for medication reconciliation

3. Event Analysis (EAs) 3 rd evaluation component Hospitals required to actively seek and investigate events that should have been prevented by the SOP EA systematic analysis of the facts & contributing factors leading to an patient safety incident (mini RCA) Link to SOP implementation

Event Analysis (EAs) 17 EAs reported by 6 hospitals No serious ADEs reported over the course of the project Most events due to a failure to undertake med rec in timely fashion Major contrib. factors were lack of teamwork, education & training and poor communication Those that did EA learnt from analysis of actual ADEs Case studies used for education of other clinicians Improved processes Business case for more resources

EA Case Study A 73 year old Parkinsons patient was admitted for investigation and rehabilitation after a fall The patient had his Webster pack with him which had clear dose times and directions to give Parkinsons medicines at 6am, 10am, 2pm, 6pm and 10pm however the MO ordered medicines for the first four dose times only omitting all the 10pm doses The omitted medicines included: levodopa/carbidopa CR200/50mg, mirtazapine 30mg, pregabalin 25mg and quetiapine 50mg There was no clinical pharmacist on the ward because the usual pharmacist was on leave with no replacement cover

EA Case Study The patient was not given doses of his usual 10pm medications for the next two days It was recorded throughout the patients notes that the patient was having multiple mobility issues. The nurse recorded that this could have been part of his usual symptoms or alternatively, a worsening of his Parkinsons symptoms i.e. Parkinsons tremor gradually worsening throughout shift

EA Case Study The treating MO asked a clinical pharmacist on a different ward to see the patient on the third day because of worsening mobility The pharmacist interviewed the patient but he was a poor historian and was unable to give an accurate medication history The pharmacist then spoke to the patients wife (carer) to establish the correct medicines as well as using the Webster Pack brought into the hospital as the 2 nd source for the BPMH After seeing the patient and taking the BPMH the medication errors were noted and the Doctor was asked to amend the medication orders The doctor re-charted all of the omitted medicines. The patients symptoms gradually abated and he recovered fully the next day

Learning from EA The process of taking a BPMH and admission reconciliation was introduced to JMOs at orientation The hospital used case study to educate JMOs on importance of using multiple sources to confirm the medication history, including blister packs Business case for additional clinical pharmacist Involving the medical and nursing staff as well as the Quality Manager in the event analysis process has resulted in new policies and actions to prevent near misses. The teamwork involved in the project has resulted in greater cooperation between clinicians which in turn has led to less medication errors (eg omission errors). (metropolitan hospital)

Commission Resources SOP & Implementation Guide MMP, user guide and flash presentation MATCH Up medicines brochures & posters BPMH Video and online learning module Consumer wallet

Conclusion Feasible to implement High 5s Medication Reconciliation SOP in different countries and cultures Requires some local and national adaptation Improves patient safety Complex process Challenging to implement, requires careful planning Measurement is critical to successful implementation Now lets hear from the hospitals

Acknowledgements High 5s hospitals Alfred Health Vic Armadale Health Service WA Epworth Healthcare Richmond Vic Greater Southern AHS NSW Logan Hospital, Qld Mater Health Services Qld Noosa Hospital Qld Medication Continuity Expert Advisory Group North West Regional Hospital TAS Prince of Wales Hospital NSW Redland Hospital NSW Rockingham Hospital WA Royal North Shore Hospital NSW The Wesley Hospital Qld

Australian Commission on Safety and Quality in Health Care www.safetyandquality.gov.au E: [email protected]

Lessons from the High 5s Project Margaret Duguid Former Pharmaceutical Advisor Helen Stark Senior...

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