Measuring the value of medication reconciliation – Part 2

Discharge processes at AHS

Tiing Tiing ChihYang Liu

Dr Stephen Lim(Acknowledgement: all senior pharmacists at AHS)

History of Med Rec at AHS

• AHS started admission MR in 2007 as part of WA SQuIRe projects

• “M+M” project – medication matching

• AHS = first hospital to introduce KPIs for Adm Med Rec• % of unintentional discrepancies = 17% Ave 17 unintentional discrepancies for 100 meds

writteni.e. for a patient on 10 medications, 1-2 of the

medications will be an unintentional discrepancy

WHO’s High 5s project from 2010

• Benefits = new measures• MR1

• 50%

• MR2• < 0.1

• MR3 • Canadian benchmark 0.3• AHS:

• MR4• Trending down, last result = 10%

• Event Analysis

Event Analysis

Event analysis beneficial as a “fact finding” tool • investigate patient safety problems

• to identify if there are problems with the SOP• to identify cause and effect

• Multidisciplinary approach• Less labour/resource intensive than RCA• Measurable actions & changes to implement to

improve patient safety

It’s discharge time!

• DC med rec started late 2007• Pharmacist involvements:

• Med list, CMI• Dispensing• Counselling• Community liaison

Discharge Process

DC script

Med chart

MMP

Med list

DC Meds

Counselling DC liaison

CMI

Pharmacist reconciliation

Discharge decision made

Medication reconciliation on discharge

Developmedication

list

Communicate D/C summary with

medication list to GP

Proactive model

Pharmacist: Reviews and reconciles :•BPMH (MMP)•Current medication charts •New medicines to start on discharge•PBS prescription•Patient’s Own MedicinesResolves discrepancies

Provide medication list to

patient

Medical officer:•Checks MMP for outstanding issues •Reconciles with medication charts•Signs off NIMC •Writes PBS script for items requiring supply

Add medication list to discharge

summary

Decision to discharge

patient

Patient shows to GP/others

Discharge summaries at AHSPrior to 2009:

•Medipal • Standalone system • “11th hour changes” not communicated

•Discharge summary sheets • Handwritten by dr on pre-printed format • Nil or only new meds listed• ?? GP liaison• ?? Patient copy

Discharge summaries at AHS

• TEDS (The Electronic Discharge System) implemented in 2009

• Pharmacists populate ADR & med list• “Import” function allows direct copying of meds

from most recent completed TEDS• On completion, GP will automatically be emailed

TEDS medication discharge list example

Current and comprehensive list of medicines •Dose changes, indications, explanations of change•Comments section: can use to provide monitoring advice•Includes stopped medications•Includes Allergies/ADRs

Discharge summaries audit

• Big improvements since TEDS implementation in 2009QUM 5.3,5.8, 5.9

Discharge Discrepancies

• Omission• Wrong dose• Wrong drug• Commission• ADR

One week DC snapshot

Total discharges surveyed = 61

No active Pcist reconciliation = 22 (36%)

•Nil MMP•Low risk pts

DC reconciliation = 39 (64%)

Pts with discrepancies = 20 (51.3%)

Average discrepancies per pt = 0.72

% incorrect meds per pt = 13%

(i.e. at least 1 error per 10 meds taken)

• PBS & legality check

• Rx to chart matching

• Med list not done by Pcist

Comparison of Adm & DC MR errors

Discharge errors Admission errors

Richard’s discharge Admitted for fast AF, CCF secondary to AF, ? Chest

infection Meds on admission:

• Thyroxine 25microg mane• Salbutamol-MDI prn

New meds:• Digoxin 125microg mane (loading 250microg x 2)• Frusemide 40mg mane• Metoprolol 12.5mg bd• Warfarin + enoxaparin tx dose until INR therapeutic• Amoxycillin 500mg tds

Richard’s DC script

Warfarin & enoxaparin missing!

Lucy’s discharge

• Admitting diagnosis: NSTEMI• Meds on admission:

• Allopurinol 100mg mane• Methyldopa 250mg bd• Paracetamol-SR 1330mg tds

• New meds started on AMU:• Aspirin 100mg mane• Ticagrelor 180mg loading then 90mg bd• Metoprolol 12.5mg bd

• DC Rx : frusemide & potassium chloride (Dr thought pt was already taking antiplatelets)

Risk factors contributing to DC discrepancies

Multiple med charts Nil MMP in place Brand name confusion Dr not referring to MMP when doing DC script

or summary Dr from different team handling DC

Challenges for DC med rec

Time / FTE Nil MMP in place Dr not contactable to verify discrepancies Late / urgent discharges

Conclusion

AHS measures coincide with High 5s measures MR6

• MR6a (% pts whose DC summaries contain a med list)• MR6b (% pts whose DC summaries contain a current, accurate

and comprehensive list of meds)• MR6c (No. discrepancies per pt)

MR7• MR7a (% pts who receive a med list)• MR7b (% pts who receive a current, accurate and

comprehensive list of meds)• MR7c (No. discrepancies per pt)