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Medication Reconciliation: Pharmacy Integrated Model Steve A. Carlson, RPh Sara E. Grove, Pharm.D....
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Transcript of Medication Reconciliation: Pharmacy Integrated Model Steve A. Carlson, RPh Sara E. Grove, Pharm.D....
Medication Reconciliation:Medication Reconciliation:Pharmacy Integrated Pharmacy Integrated Model Model
Steve A. Carlson, RPhSara E. Grove, Pharm.D.
Northeast Georgia Health System (NGHS)Gainesville, Georgia
Best Practice Power HourBest Practice Power Hour
NGHSNGHS
Private, not-for-profit, community Accredited by DNV 557 inpatient beds 261 skilled nursing beds Serves almost 700,000 people in more
than 13 northeast Georgia counties
Inpatients 30,364 Outpatients 238,542 Surgeries
Outpatient 10,801 Inpatients 7,466 Emergency Visits 99,456
Deliveries 4,087
Patients ServedPatients Served
32.04 Pharmacists (including management) 6 Clinical Pharmacy Specialists
Department of PharmacyDepartment of Pharmacy
41 Technicians (3:1 ratio in GA) Unit-Based Pharmacy Technicians
Cardiology Critical Care Internal Medicine
Oncology Women & Children’s Health Emergency Medicine
Cardiology Critical Care Internal Medicine
Oncology Women & Children’s Health Emergency Medicine (2)
* Reflects staffing only at the medical center
Customer Service is a major focus of the facility Patient Staff
Developed a Unit-Base Pharmacy Technician Model
Providing Exceptional Providing Exceptional ServiceService
Unit-BasedUnit-Based Pharmacy Pharmacy Technician (UBT) ProgramTechnician (UBT) Program
Established in February 2007 Initially 4 Pairs of Technicians Goals
Optimize Distribution Establish Direct Communication Provide Focused Service
Qualified Staff Certified Technicians Experienced Senior Staff
Review of EventsReview of Events
January 2006: Nurse Managers Interviewed March 2006: Base-Line Survey Conducted May 2006: Results Presented May 2006: Pilot on 2 Floors Conducted July 2006: Proposal Presented & Approved November 2006: Initial Deployment February 2007: Full Implementation March 2007: Survey Repeated May 2007: Results Presented July–August 2007: Focus Groups Met
Initial FTE RequirementsInitial FTE Requirements
7.6 FTE’s; 10 hour shifts 7on / 7off Open pharmacist position (1 FTE)
converted to 2.8 FTE’s Redeployed 2.0 FTE’s Requested a net of 2.8 new FTE’s
UBT ResponsibilitiesUBT Responsibilities
Delivery of medications directly to nurse or nurse server
Resolution of missing medications Facilitating transfer of medications
on/off unit with patient Removal/return of discontinued meds Automated Dispensing Cabinet
troubleshooting/restock
UBT ResponsibilitiesUBT Responsibilities
Delivery of cart fill to nurse server Med error/ADR reporting to
pharmacist Notification of allergy/height/ weight Monthly nursing unit inspections Assistance with faxing of orders Obtain new orders from units and
expedite medication needs
2006 2007
Pharmacy Customer Service SurveyPharmacy Customer Service SurveyAll Nursing Units - Medical Center
Pharmacy Customer Service SurveyPharmacy Customer Service Survey
2006 2007
Areas Serviced by Unit-Based Technicians - Medical Center
Survey Comments and Survey Comments and SuggestionsSuggestions
“These techs are the smartest thing I’ve seen around here in a long time. They are beyond measure – an asset to having quality – acceptable nursing care.”
“Excellent teamwork – assists nurses to complete essential nursing tasks & focus on this vs. non-nursing duties.”
“Go unit based techs! You rock.”
Survey Comments and Survey Comments and SuggestionsSuggestions
“Still have a problem with medication missing, but turn around time to get it is much better.”
“The morning meds that are due before breakfast…are scheduled at 0730 and this isn’t working well. By the time we get out of report, the breakfast trays have already been passed. Can these meds please be scheduled for 0630?”
Reconciliation ProcessReconciliation Process
Home
Transfer
DischargeAdmission
Home Med List Created
Addressed by MD
Reconciled by RPh List Provided to Next
Provider of Care
Reconciled by MD
Addressed & Reconciled
by MD
New Home Med List
Created
Communicated to Patient by Nurse
Identifying Deficiencies Identifying Deficiencies
• Discharge Medication List • Heart Failure Core Measure HF-1 Scores
• Average Fiscal Year 2008: 53.4%
• TJC Average: 75.8%
• Majority of failures due to transcription errors
• Admission Medication List• Staff observed errors and omissions
• Garbage In / Garbage Out
NGHS Performance Improvement Dashboard
Medication Reconciliation Medication Reconciliation ResponsibilitiesResponsibilities Admission
• Interview patient at admission• Document home medication list• Print list for physician to address
Discharge• Document discharge medication list as
specified by physician orders• Notify nurse of discrepancies
Technician TrainingTechnician Training
Software• Demonstrate Proficiency in Entry
Procedure• Identify Discrepancies
Communication• Demonstrate Appropriate Body Language
• Review Principle
• Identify Barriers
Pilot: Heart FailurePilot: Heart Failure
Pharmacist Pre-Pilot• October to Mid-December 2008
Locations• Emergency Department
• 3 Medical/Cardiac Inpatient Units
Redistribution of Workload• Reduced # Beds/UBT
• Added 3 Positions per Week
Pharmacy-Based Medication Reconciliation PilotPharmacy-Based Medication Reconciliation PilotStarts December 16Starts December 16thth
Floors Participating: S3E S4D S4E ED
1) To improve patient safety and care by striving to optimize the medication reconciliation process2) To demonstrate improvement through increased Heart Failure Core Measure scores
Goals:
Here to Help
Rx
•Interview admitted patients and document current home medication list
•If medication history is needed immediately and a pharmacy technician is not available, collect and document current home medication list
•Record “MD Discharge Medication Orders” in Clinical Profile
•Resolve discrepancies with physician
Pharmacy Tech Duties Nurse DutiesAdmission
Discharge
•Print “Admission Medication List” and attach it to the chart
•Notify nursing of any discrepancies
•Sign “MD Discharge Medication Orders” to indicate completion
•Counsel the patient on discharge medications and instructions•Sign “Patient Discharge Medication List”
Coverage from 0700-2300Coverage from 0700-2300
•Late admissions will be completed the following morning
•Review and sign off “MD Discharge Medication Orders”
Here to Help
Rx
Technician-Assisted Technician-Assisted Medication ReconciliationMedication Reconciliation
NGHS Performance Improvement Dashboard
HF-1 Score Adjusted Score
2008 Average 53.4% --
1st Quarter 2009 75.4% 92.1%
2nd Quarter 2009 70.1% 85%
January 63.6% 77.3%
February 72.7% 86.4%
March 73.9% 91.3%
Cumulative HF ScoresCumulative HF Scores
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
1st Qrt 08
2nd Qrt08
3rd Qrt08
4th Qrt 08
1st Qrt 09
2nd Qrt09
3rd Qrt09
4th Qrt 09
1st Qrt 10
2nd Qrt10
3rd Qrt10
4th Qrt 10
1st Qrt 11
HF-1 Score Pharmacy Adjusted Score
Opportunities for Opportunities for ImprovementImprovement
Nurse/Technician Clarifications Developed a formal discrepancy form
Discharge Summary Development of electronic bridge
Improperly Completed Forms Form revision
Discrepancy ReasonsDiscrepancy Reasons
Therapeutic Interchange New Prescription Duplicate Therapy Medication Not Addressed No Prescription Inappropriate Form Completion Inappropriate Alteration of Form