Section 2.0: Medication Safety during Transitions of Care ... Section 2.0: Medication Safety during...
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1 Section 2.0: Medication Safety during Transitions of Care: Clinical Implications – Introduction Pharmacists are a valuable resource for patients and healthcare professionals to optimize medication efficacy and safety. Senior care pharmacists are specially trained in elder co- morbidities and complex medication management. During transitions of care, pharmacists are in a unique position of interfacing with patients in all care settings. Care transitions thus present the opportunity for pharmacists to demonstrate their clinical expertise to yield positive clinical outcomes and improve quality care. The Medication Safety during Transitions of Care (MSTOC) Toolkit includes a multitude of practical clinical resources for pharmacists in any care setting. The “Clinical Implications” portion of the toolkit is a collection of resources, guidance and links to materials intended to assist in identifying and focusing on key medication classes and disease states to optimize medication safety during transitions of care. The clinical implications portion of the toolkit is divided into the following six sections: • Section 2.1 Tools to Identify Key Disease States • Section 2.2 Tools to Identify High Risk Medications • Section 2.3 Tools to Identify Potentially Inappropriate Medications • Section 2.4 Tools to Classify Medication-Related Problems & Medication Errors • Section 2.5 Tools to Manage Medications Safely • Section 2.6 Tools to Improve Transitions of Care Processes Each section includes background information and an introductory overview of included resource materials. Sections are also accompanied by summary PowerPoint © slides that may stand alone as teaching modules to provide education to pharmacist colleagues or other healthcare professionals. Medication Safety during Transitions of Care: Clinical Implications Section 2.1: Tools to Identify Key Disease States The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) is designed to improve health care for people with Medicare by linking hospital payments to quality of care rather than quantity of services provided.
Transcript of Section 2.0: Medication Safety during Transitions of Care ... Section 2.0: Medication Safety during...
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Section2.0:MedicationSafetyduringTransitionsofCare:ClinicalImplications–IntroductionPharmacistsareavaluableresourceforpatientsandhealthcareprofessionalstooptimizemedicationefficacyandsafety.Seniorcarepharmacistsarespeciallytrainedinelderco-morbiditiesandcomplexmedicationmanagement.Duringtransitionsofcare,pharmacistsareinauniquepositionofinterfacingwithpatientsinallcaresettings.Caretransitionsthuspresenttheopportunityforpharmaciststodemonstratetheirclinicalexpertisetoyieldpositiveclinicaloutcomesandimprovequalitycare.TheMedicationSafetyduringTransitionsofCare(MSTOC)Toolkitincludesamultitudeofpracticalclinicalresourcesforpharmacistsinanycaresetting.The“ClinicalImplications”portionofthetoolkitisacollectionofresources,guidanceandlinkstomaterialsintendedtoassistinidentifyingandfocusingonkeymedicationclassesanddiseasestatestooptimizemedicationsafetyduringtransitionsofcare.Theclinicalimplicationsportionofthetoolkitisdividedintothefollowingsixsections:
• Section2.1ToolstoIdentifyKeyDiseaseStates• Section2.2ToolstoIdentifyHighRiskMedications• Section2.3ToolstoIdentifyPotentiallyInappropriateMedications• Section2.4ToolstoClassifyMedication-RelatedProblems&
MedicationErrors• Section2.5ToolstoManageMedicationsSafely• Section2.6ToolstoImproveTransitionsofCareProcesses
Eachsectionincludesbackgroundinformationandanintroductoryoverviewofincludedresourcematerials.SectionsarealsoaccompaniedbysummaryPowerPoint©slidesthatmaystandaloneasteachingmodulestoprovideeducationtopharmacistcolleaguesorotherhealthcareprofessionals.MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.1:ToolstoIdentifyKeyDiseaseStatesTheCentersforMedicare&MedicaidServices(CMS)HospitalReadmissionsReductionProgram(HRRP)isdesignedtoimprovehealthcareforpeoplewithMedicarebylinkinghospitalpaymentstoqualityofcareratherthanquantityofservicesprovided.
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TheHRRPprovidesfinancialincentivestohospitalstoreducecostlyandunnecessaryhospitalreadmissionsthroughbettercoordinationofcaretransitionsandimprovedqualityofcaregiventopatientswithMedicare.InOctober2012,CMSbeganreducingMedicarepaymentsforInpatientProspectivePaymentSystem(IPPS)hospitalswithexcessreadmissions.Whentheprogramstarted,hospitalsweremeasuredforthereadmissionratesofpatientswiththefollowingkeydiseasestates:acutemyocardialinfarction(AMI),heartfailure,andpneumonia.In2012,COPD,electivehip/kneereplacementandcoronaryarterybypassgraftsurgerywereaddedtothislist.Excessreadmissionsaremeasuredbyaratiodividingahospital’snumberof“predicted”30-dayreadmissionsforthesekeydiseasestatesbythenumberthatwouldbe“expected”inanaveragehospitalwithsimilarpatients.Aratiogreaterthan1.0000indicatesexcessreadmissions.Hospitalsattemptingtolowertherateofreadmissionsare:
• Focusingonbettercoordinationofcareandcommunicationbetweenproviders,patientsandtheircaregivers.
• Improvingdischargeplanning,educationandfollow-upfordischargedpatients.• Usingelectronicmedicalrecordstoshareinformationandprovidecontinuityofcare.
Whilepharmacistinvolvementinallcaretransitionsisbeneficial,focusingonthekeydiseasestatesmeasuredintheHRRPwillenhancethevalueofpartnershipsbetweenhospitalsanddownstreamcaresites(e.g.long-termcare,post-acutecarerehabilitation,community).
• Resource:ThislinksdirectsyoutoCMS’scomprehensiveinformationontheHRRPProgram:https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html
MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.2:ToolstoIdentifyHighRiskMedicationsThereismuchliteratureontheidentificationofhighriskmedications.A2014reportbytheUSDepartmentofHealthandHumanServices’OfficeofInspectorGeneral(OIG)foundthat22%ofMedicarebeneficiariesinskillednursingfacilitiesexperienceadverseeventswithinthefirst35daysoftheirstay.Oftheseidentifiedadverseevents,37%wererelatedtomedicationsandprimarilyassociatedwithconditionstreatedwithhypoglycemics,anticoagulantsandopiates.Attheconclusionofthereport,theOIGrecommendedthatCMScollaboratewiththeAgencyforHealthcareResearchandQuality(AHRQ)toincreaseawarenessofadverseeventsinnursing
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homesandtodevelopsafetymethodologiestoreducetheseevents(i.e.creatingofalistofpotentialnursinghomeadverseevents).
• Resource:Thislinkdirectyouto2014OIGreport:http://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf
AdverseEventsinNursingHomesInresponsetorecommendationsfromthe2014OIGreportabove,CMSincorporatedresourcesinitsQualityAssurance&PerformanceImprovement(QAPI)websitetohelphealthcareprovidersidentifyandinvestigateadverseevents(AEs)innursinghomes.CMSalsoencouragesthedevelopmentofsystem-wideprocessesdesignedtomitigateAErisk.
• Resource:ThislinkdirectsyoutoCMS’sQAPIsiteonAEsinnursinghomes:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Adverse-Events-NHs.html
OnetoolontheCMSQAPIsitelistspotentialAEsinnursinghomes.UsingtheOIGreport,CMSandAHRQcollaboratedtocreatealistofthemostcommonpotentiallypreventableAEsrelatedtomedications,residentcareandinfections.
• Resource:ThislinkdirectsyoutoalistofpotentiallypreventableAEswithintheCMSQAPIsite:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/Potentially-Preventable-Adverse-Events.pdf
CMSAdverseDrugEventTriggerToolThirtysevenpercentofAEsidentifiedinthe2014OIGreportwereadversedrugevents(ADEs)involvingmedications.ThesecondmostfrequentADEwasexcessivebleedingrelatedtoanticoagulantuse.Thesefindingscontinuetobesupportedintheliterature.CMSdevelopedaresourcedocumentthatlistscommonpotentiallypreventableADEs,riskfactorsrelatedtothoseevents,triggers(i.e.signs,symptoms,interventions)whichcouldindicatethatanADEoccurred;andsurveyorprobestoassistintheevaluationofhighriskmedicationsafetysystems.
• Resource:ThislinkdirectsyoutotheADEtriggertoolwithintheCMSQAPIsite:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/Adverse-Drug-Event-Trigger-Tool.pdf
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CMSFocusedSurveyonMedicationSafetySystemsDuringitscollaborationwithAHRQ,CMSbegindevelopingandtestingaFocusedSurveyonMedicationSafetySystemstolookatnursinghomepracticearoundhigh-riskandproblempronemedications.Theabove-mentionedCMSAdverseDrugEventTriggerToolandlistsofpotentiallypreventableAEsareessentialcomponentsofthissurveyprocess.AsofAugust2017,thisfocusedsurveyremainsinpilotphase.Itwilllikelybecomepartoftheannualstatesurveyprocessinthefuture.ThesurveyessentialsincludeareviewofmedicationsafetysystemsthatidentifypreventableADEsandtheriskfactorsrelatedtothoseevents.
• ReviewmedicationsafetysystemsusingADEtriggertool• IdentifypreventableADEsthathaveoccurredorwilloccur• MitigateriskfactorsrelatedtoADEs
• Resource:ThislinkdirectsyoutotheCMSMemoannouncingtheMedicationSafety
SystemsFocusedSurvey:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-47.html
InstituteforHealthcareImprovement(IHI)High-AlertMedicationSafetyResourcesInefforttoimprovehealthandhealthcareworldwide,theInstituteforHealthcareImprovement(IHI)websiteincludesnumerousresourcesandtoolsrelatedtomedicationsafety.Thehigh-alertmedicationsafetypagedefineshigh-alertorhigh-hazardmedicationsasdrugsmostlikelytocausesignificantharm,especiallywhenusedinerrorbutevenwhenusedasintended.TheIHItoolsfocusonmedicationclassesthatmorefrequentlycauseharm(i.e.anticoagulants,narcotics,opiates,sedativesandinsulinwhichcancauseAEssuchasbleeding,somnolence,hypotensionandhypoglycemia).Recognizingthatsafemedicationpracticescanreducethepotentialforharm,IHIalsodevelopedahow-toguidetopreventharmfromhigh-alertmedications.
• Resource:AccessingtheIHItoolsrequiresfreeregistration.Thislinkdirectsyoutothehigh-alertmedicationsafetysectionofIHIsite:http://www.ihi.org/topics/highalertmedicationsafety/pages/default.aspx
InstituteforSafeMedicationPractices(ISMP)ListsofHigh-AlertMedicationsOnerecommendedresourceontheIHIpageisTheInstituteforSafeMedicationPractices(ISMP)listsofhigh-alertmedicationsincommunity/ambulatoryandacutecaresettings.The
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community/ambulatorylistincludes8categoriesand8specificmedications.Theacutecaresettinglistincludes22categoriesand12specificmedications.TheselistsareperiodicallyupdatedbasedonerrorreportssubmittedtotheMedicationErrorsReportingProgram(MERP),reportsofharmfulerrorsintheliterature,andinputfrompractitionersandsafetyexperts.
• Resource:ThislinkdirectsyoutoISMP’sprintablepdflistofhigh-alertmedicationsincommunity/ambulatoryhealthcare:http://ismp.org/communityRx/tools/highAlert-community.pdf
• Resource:ThislinkdirectsyoutoISMP’sprintablepdflistofhigh-alertmedicationsin
acutecaresettings:http://www.ismp.org/Tools/highalertmedications.pdf
HEDIS®MeasuresTheHealthcareEffectivenessDataandInformationSet(HEDIS®)isasetofhealthcareperformancemeasuresthatdatebacktothe1980s.HEDIS®isnowaregisteredtrademarkoftheNationalCommitteeforQualityAssurance(NCQA)thatcollectsqualitymeasuresforphysicians,PPOsandotherorganizationsonbehalfofCMSandstateagencies.HEDIS®consistsof81specificmeasuresover5domainsofcare.SurveydataiscollecteddirectlyfromhealthplansandPPOsthroughtheHealthcareOrganizationQuestionnaire(HOQ).NonsurveydataiscollectedthroughtheInteractiveDataSubmissionSystem(IDSS).HEDISisdesignedtoprovidepurchasersandconsumerswiththeinformationtheyneedtoreliablycomparetheperformanceofhealthcareplans.NCQA’smeasuresaddressstandardizedperformancemeasuresforcareofchronicconditionssuchasasthma,diabetes,chronicobstructivepulmonarydisease(COPD),heartfailure(HF)andischemicvasculardisease(IVD),aswellaspreventativemeasuresfortobaccouse,influenzavaccinationandpneumococcalvaccination.“UseofHRMsintheElderly”isonemetricincludedinHEDIS2017thatcalculates:
• %ofmembers66yearsandolderwhoreceivedatleastoneHRM• %ofmembers66yearsandolderwhoreceivedatleasttwoHRMs
TheNationalDrugCode(NDC)ListsincludeHRMsthatalignwiththe2015AmericanGeriatricsSocietyBeersCriteria.
• Resource:ThislinkdirectsyoutotheNDCListprovidedontheNCQAsite:http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017/hedis-2017-ndc-license/hedis-2017-final-ndc-lists
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Section2.3:ToolstoIdentifyPotentiallyInappropriateMedicationsPotentiallyinappropriatemedications(PIMs)arethosewhoseuseinolderadultshasproducedevidenceofpooroutcomes.PIMsuseinvulnerableolderadultsisincorporatedintomanyqualityandsafetymeasures.AmericanGeriatricsSociety(AGS)BeersCriteria2015TheAGSBeerscriteriaisonesourceofidentifyingPIMsbestavoidedinolderadults.The2012AGSBeersCriteriawereupdatedin2015toincorporatenewevidenceoncurrentlylistedPIMsandnewmedicationsandconditionsnotpreviouslyaddressedinthecriteria.Neededexceptionswerealsoaddedtothecriteriatomakethemmoreindividualizedandrelevant.EachPIMrecommendationisnowgradedbasedonstrengthandlevelofevidenceonmedication-relatedproblems(MRPs)andadversedrugevents(ADEs).ThefinalupdatedCriteriaaredividedintothreecategories:
• Table2:PIMUseinOlderAdults• Table3:PIMUseinOlderAdultsDuetoDrug-DiseaseorDrug-SyndromeInteractions
thatMayExacerbatetheDiseaseorSyndrome• Table4:PIMstobeUsedwithCautioninOlderAdults
Newcompanionresourcesinthe2015editioninclude:how-to-useguide,alternativetherapiesforPIMs,moredetailedguidancefordrug-druginteractionsandrenaldoseadjustments,pocketcards,andpatienteducationmaterials.ItisimportanttonotethattheBeerscriteriaarenotapplicabletoseniorsrequiringpalliativeorhospicecare.
• Resource:Thislinkdirectsyoutothe2015Beerscriteriaandassociatedresources:http://geriatricscareonline.org/toc/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001
ZhanCriteriaforPIMUseintheElderlyZhanmodifiedthe1997BeersCriteriatofocusonidentifyingPIMuseinthecommunity-dwellingelderly.Apanelofexpertsclassified33medicationsfromtheBeersCriteriaintothreecategories:drugsthatshouldalwaysbeavoided,arerarelyappropriate,orhavesomeindicationsbutareoftenmisused.PrevalenceofuseofthesePIMswasmeasuredusingthe1996MedicalExpenditurePanelSurvey,anationallyrepresentativesurveyoftheU.S.non-institutionalizedpopulation.RiskfactorsforPIMuseidentifiedinthisstudyincludepoorhealthandpolypharmacy.
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ZhanCriteriaContinued
• Resource:ThisisthecitationfortheZahncriteria:ZhanC,SanglJ,BiermanAS;etal.Potentiallyinappropriatemedicationuseinthecommunity-dwellingelderly:findingsfromthe1996MedicalExpenditurePanelSurvey.JAMA.2001;286(22):2823-9.
ScreeningToolofOlderPeople'sPrescriptions(STOPP)andScreeningTooltoAlerttoRightTreatment(START)CriteriaforPotentiallyInappropriatePrescribinginOlderPeople:Ver2TheScreeningToolofOlderPeople'sPrescriptions(STOPP)andScreeningTooltoAlerttoRightTreatment(START)CriteriaforPotentiallyInappropriatePrescribinginOlderPeoplewerefirstpublishedin2008.In2015,theseoriginalcriteriawerereviewedtoaddnewevidence-basedcriteriaandremoveanyobsoletecriteria.ThepurposeoftheSTOPPcriteriaistominimizeinappropriateprescribingtodecreaseadverseclinicaloutcomesinolderadultswhilethepurposeoftheSTARTcriteriaistoidentifypotentialprescribingomissionsinolderadults.UnlikeBeersCriteriamedications,STOPPcriteriamedicationsaresignificantlyassociatedwithadversedrugevents(ADEs).STOPP/STARTcriteriahavepracticalclinicalvalueinthattheycanbeappliedasasingleinterventiontoimprovemedicationappropriatenessandreducetheincidenceofADEs.
• Resource:Thisisthecitationforthe2015STOPP/STARTcriteria:DenisO'Mahony,DavidO'Sullivan,StephenByrne,etal.STOPP/STARTcriteriaforpotentiallyinappropriateprescribinginolderpeople:version2,AgeandAgeing.2015;44(2):213-8https://doi.org/10.1093/ageing/afu145
AmericanGeriatricsSociety(AGS)WorkwiththeAmericanBoardofInternalMedicine(ABIM)Foundation's“ChoosingWisely®”CampaignAGSpartneredwiththeABIMFoundation’s“ChoosingWisely®”Campaigntoimprovequalityofcareanddecreaseunnecessaryhealthcarespending.Thiscampaignisdesignedtoeducatepatients,healthcareprofessionals,andfamilycaregiversaboutsafetyandefficacyofvarioushealthcarechoices.AGS’slistof“TenThingsCliniciansandPatientsShouldQuestion”includespotentiallyinappropriateprescribingforthefollowingmedicationclasses:antipsychoticsforbehavioralandpsychologicalsymptomsofdementia;hypoglycemictoachieveanHbA1clessthan7.5%;sedative/hypnoticsforinsomnia,agitationordelirium;antimicrobialsforasymptomaticbacteriuria;cholinesteraseinhibitorsfordementia;andappetitestimulantsforanorexiaorcachexia.
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OneAGSrecommendationis:“Don’tprescribeamedicationwithoutconductingadrugregimenreview”becausepolypharmacyincreasesriskforsideeffects,inappropriateprescribing,diminishedadherence,adversedrugreactions,cognitiveimpairment,fallsandfunctionaldecline.Medicationreviewmayidentifyhigh-riskmedications,drug-druginteractions,medicationscontinuedbeyondtheirindication,unnecessarymedicationsandunderuseofmedications,andmayreducemedicationburden.
• Resource:ThislinkdirectsyoutoalltheAGSrecommendationsontheChoosingWisely®
site:http://www.choosingwisely.org/societies/american-geriatrics-society/MedicationAppropriatenessIndex(MAI)Hanlon’sMedicationAppropriatenessIndex(MAI)wasdevelopedtodetectpotentiallyinappropriateprescribingwithasetof10explicitquestionsthatpredictadversehealthoutcomes.Thequestionnaireasks:
1. Isthereanindicationforthedrug?2. Isthemedicationeffectiveforthecondition?3. Isthedosagecorrect?4. Arethedirectionscorrect?5. Arethedirectionspractical?6. Arethereclinicallysignificantdrug-druginteractions?7. Arethereclinicallysignificantdrug-diseaseinteractions?8. Isthereanyunnecessaryduplicationwithotherdrugs?9. Isthedurationoftherapyacceptable?10. Isthisdrugtheleastexpensivealternativecomparedtoothersofequalutility?
StudiesontheMAIdemonstratethepositiveimpactpharmacistinterventionshaveonimprovingpotentiallyinappropriateprescribinginolderadults.
• Resource:ThisisthecitationfortheMAIquestionnaire:HanlonJT,SchmaderKE,SamsaGP,etal.Amethodforassessingdrugtherapyappropriateness.JClinEpidemiol.1992;45:1045–51.
Assess,Review,Minimize,Optimize,Reassess(ARMOR)ToolTheAssess,Review,Minimize,Optimize,Re-assess(ARMOR)toolisafunctional,interactiveevidence-basedtool.Thetooltakesintoaccountclinicalprofiles,functionalstatus,andphysiologicreservestoimprovefunctionalstatusandmobilityandmakedecisionsaboutchangingordiscontinuingmedications.
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TheARMORtoolisdesignedforuseinSNFresidents:
• Receiving9ormoremedications• Initialassessment• Withfallsorbehavioraldisturbance• Admittedforrehabilitation
Whentestedononenursingfacility,theARMORtoolreducedpolypharmacy,healthcarecosts,andhospitalizations.
• Resource:ThisisthecitationfortheARMORtool:HaqueR.ARMOR:atooltoevaluatepolypharmacyinelderlypersons.AnnalsofLong-TermCare2009;17(6):26–30.
MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.4:ToolstoClassifyMedication-RelatedProblems&MedicationErrorsAnumberoftoolsareavailabletotrackandquantifymedicationerrors,adversedrugevents(ADE)andpotentialadversedrugevents(pADE).Food&DrugAdministration(FDA)MedWatchTheFDA’sMedWatchisaSafetyInformationandAdverseEventReportingProgram.Thisvoluntaryonlinereportingformcanbecompletedbyeitherhealthcareprofessionalsorconsumerstoreportobservedorsuspectedadverseevents(AEs)whichmayinclude:seriousdrugsideeffects,medicationerrors/productuseerrors,productqualityproblems,ortherapeuticfailures.ReportedAEsmayinvolveanyhumanmedicalproduct(i.e.prescriptionorover-the-counterdrugs,biologics,medicaldevices,specialnutritionals,cosmetics,orfoods/beverages).Thereporterispromptedtoenterinformationaboutthepatient,problem,product,device,concomitantproducts,andthemselves.Basedonfiledreports,theFDAreleasestimelysafetyalertsforhumanmedicalproducts(i.e.medications,biologics,medicaldevices,specialnutritionals,andcosmetics).Thesesafetyalertscontainactionableinformationthatmayimpacttreatmentanddiagnosticchoicesforhealthcareprofessionalandconsumers.YoucansignuptoreceiveMedWatchsafetyalertsviae-mail,Twitter©,andRSS.
• Resource:ThislinkdirectsyoutoFDAMedWatch:https://www.fda.gov/safety/medwatch/default.htm
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NationalCoordinatingCouncilforMedicationErrorReportingandPrevention(NCCMERP)IndexTheNationalCoordinatingCouncilforMedicationErrorReportingandPrevention(NCCMERP)definesamedicationerroras“anypreventableeventthatmaycauseorleadtoinappropriatemedicationuseorpatientharmwhilethemedicationisinthecontrolofthehealthcareprofessional,patientorconsumer.Sucheventsmayberelatedtoprofessionalpractice,healthcareproducts,procedures,andsystems,includingprescribing,ordercommunication,productlabeling,packaging,andnomenclature,compounding,dispensing,distribution,administration,education,monitoring,anduse.”NCCMERPcreatedaMedicationErrorIndextostandardizecharacterizationofmedicationerrors.Thisindexconsidersiftheerroractuallyoccurred,iftheerrorreachedthepatient,ifthepatientwasharmedandifso,towhatdegree.Theindexisavailableasbothapiechartandanalgorithmanddefinesthefollowingterms:harm,monitoring,interventionandinterventionnecessarytosustainlife.
• Resource:ThislinkdirectsyoutotheNCCMERPIndex:http://www.nccmerp.org/types-medication-errors
InstituteforSafeMedicationPractices(ISMP)MedicationErrorReportingProgram(MERP)TheNCCMERPindexisusedbytheInstituteforSafeMedicationPractices(ISMP)MedicationErrorReportingProgram(MERP)nationaldatabase.ISMPoperatesthisconfidential,voluntaryreportingprogramtolearnanddisseminateinformationaboutthecausesandfactorsthatcontributetomedicationerrors.ISMPdefinesanADEas“adeviationinthemedicationuseprocessoranundesirableclinicalmanifestationthatisconsequenttoandcausedbytheadministrationoromissionofmedications”andapADEas“ahazardoussituationthatcouldleadtoanerror.”
• Resource:ThislinkdirectsyoutotheISMPsitetoreportamedicationorvaccineerrororhazard:https://www.ismp.org/errorReporting/reportErrortoISMP.aspx
MedicationErrorandAdverseDrugEventReportingSystem(MEADERS)
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TheMedicationErrorandAdverseDrugEventReportingSystem(MEADERS)isusedbytheAgencyforHealthcareResearchandQuality(AHRQ)toreportmedicationerrorsandADEsandpADEs.LikeISMP’sMERPindex,thissystemisalsolinkedtoFDAMedWatch.
• Resource:ThislinkdirectsyoutoAHRQ’sMEADERS:http://www.ahrq.gov/news/events/nac/2012-07-nac/brady/brady0712sl14.html
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VeteransAffairsDrugEventReportingSystem(VADERS)TheVeteranAffairsDrugEventReportingSystem(VADERS)wascreatedtoprovideanelectronicADEreportingtoolfortheVAsystem.UnlikeAHRQ’sMEADERS,pADEsarenotreportedinVADERS.LikeISMP’sMERPandAHRQ’sMEADERS,thissystemisalsolinkedtotheFDAMedWatch.
• Resource:ThislinkdirectsyoutoVADERS:http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3043
UniversityofSouthernCalifornia(USC)MedicationTherapyInterventionandSafetyDocumentationProgramTheUniversityofSouthernCalifornia(USC)MedicationTherapyInterventionandSafetyDocumentationProgrampresentsaprocessforidentifyingandtrackingmedication-relatedproblemsthatrequireinterventionorrecommendationbyapharmacist.ThistoolidentifiesandratesseverityofADEsandpADEswhilequantifyingtheimpactpharmacyserviceshasonqualityandsafetyofmedicationuse.Sincethisprogramispaper-based,itisnotlinkedtotheFDAMedWatch.
• Resource:ThislinkdirectsyoutoUSC’smedicationsafetyprogramdetailedusermanual:http://www.ihconline.org/UserDocs/Pages/USC-Medication-Therapy-Intervention-and-Documentation-Manual--Updated-4-6-2012.pdf
MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.5:ToolstoManageMedicationsSafelyThissectionisdividedinto8Parts:
• Part2.5.1:Anticoagulants• Part2.5.2:Hypoglycemics• Part2.5.3:Opioids• Part2.5.4:Psychotropics• Part2.5.5:Antimicrobials• Part2.5.6:NarrowTherapeuticIndexMedications• Part2.5.7:Anticholinergic/Sedation/FallRiskMedications• Part2.5.8:Pharmacogenomics
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Part2.5.1:AnticoagulantsAnticoagulantsareamongthethreeclassesofmedicationsmostcommonlyassociatedwithadversedrugreactions(ADRs)innursinghomes.StandardizationofpracticescangreatlyreduceADRsfromanticoagulants.TheUniversityofMichiganAnticoagulationToolkitwasproducedbytheMichiganAnticoagulationQualityImprovementInitiative(MAQI2)toprovidehealthcareprofessionalswithup-to-date,reliable,easy-to-useinformationforanticoagulation.Thistoolkitincludes:
• Riskevaluationtoolsforatrialfibrillation,VTE,andbleedingrisk,includingonlinecalculatorsandapps
• Guidanceonanticoagulantselection• Initiationguides,patienteducationmaterials,andlong-termmanagementtoolsfor
warfarinandDOACs
ThistoolkitcanalsobeaccessedthroughaniPhoneapplication.
• Resource:ThislinksdirectsyoutotheMAQI2AnticoagulationToolkit:http://www.anticoagulationtoolkit.org/sites/default/files/toolkit_pdfs/toolkitfull.pdf
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TheInstituteforSafeMedicationPractices(ISMP)providesanumberofservicestoimprovemedicationsafetywithanticoagulationtherapy,including:
• ISMPmedication-safetyself-assessmentforantithrombotictherapy• FailureModeandEffectsAnalysis(FMEA)• Recordedaudioteleconferencesandothereducationalprograms
• Resource:ThislinksdirectsyoutotheISMPImprovingMedicationSafetywith
AnticoagulationTherapypage:http://www.ismp.org/tools/anticoagulantTherapy.asp
TheInstituteforHealthcareImprovement(IHI)proposesmultiplechangesforimprovementtoreduceadverseeventsinvolvinganticoagulants.Suggestedchangesforimprovementinclude:
• Useguidelinesforpre-printedordersforVitaminK• Developawarfarindosingserviceorclinic• Continuetouseanticoagulationflowsheetsafterdischarge• Educatepatientstomanagewarfarintherapyathome
• Resource:ThislinksdirectsyoutotheIHI:ReduceAdverseDrugEventsInvolving
Anticoagulantspage:http://www.ihi.org/resources/Pages/Changes/ReduceAdverseDrugEventsInvolvingAnticoagulants.aspx
Part2.5.2:HypoglycemicsHypoglycemicsareamongthethreeclassesofmedicationsmostcommonlyassociatedwithadversedrugreactionsinnursinghomes.Diabetesismorecommoninolderadultsandisassociatedwithsignificantdiseaseburdenandhighercost.Asthesepatientstransitionfromonesettingtoanother,oneprovidertoanother,theirriskforadverseeventsincreases.ThepositionoftheAmericanDiabetesAssociationisthatdiabeticgoalsandmanagementshouldbetailoredbasedoncomorbiditiesandregimensshouldbesimplifiedtowardshigherclinicaltargets.Furthermore,thesoleuseofslidingscaleinsulin(SSI)shouldbeavoidedinseniors.
• Resource:ThislinksdirectsyoutotheADAStandardofCare:Diabetesmanagementinlong-termcareandskillednursingfacilities:
http://care.diabetesjournals.org/content/39/2/308
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• Resource:ThislinksdirectsyoutotheADAStandardofCare:Glycemiccontrolinolder
adults:http://care.diabetesjournals.org/content/diacare/39/Supplement_1/S81.full.pdf
• Resource:ThislinksdirectsyoutotheSocietyofHospitalMedicine:TheGlycemicControlImplementationGuidehttp://tools.hospitalmedicine.org/resource_rooms/imp_guides/GC/GC_Workbook.pdf
Part2.5.3:OpioidsOpioidsareamongthethreeclassesofmedicationsmostcommonlyassociatedwithadversedrugreactionsinnursinghomes.In2016,theCDCreleasedguidelinesforprescribingopioids.Opioidprescribinghasincreased7.3%from2007to2012with259millionprescriptionswrittenin2012.Therearefewstudiesthathavebeenconductedtoassessthelong-termbenefitsofopioidsforchronicpainvs.long-termeffects,howevertheuseofopioidpainmedicationhasseriousrisks,includingoverdoseandopioidusedisorder.Guidelinesrecommendtreatingchronicnon-cancerpainwithnon-pharmacologicalandnon-opioidmedicationsandtoonlyuseopioidswhenbenefitsoutweighrisks.Theconcurrentuseofopioidsandbenzodiazepinesaretobeavoidedaswell.Thereisconsiderablevariationsinotherfactorsofopioidprescribingincludingdosagethresholdsbasedonmorphinemilligramequivalentsdaily,whoshouldbeprescribing,theuseofevidenceandconflictofinterest.Thereareseveraltoolsintheresourcestohelpwithopioiddosing,conversionandpainassessment:
• Resource:ThislinksdirectsyoutotheInteragencyGuidelineonPrescribingOpioidsforPainbyWashingtonStateMedicalDirectorsGroup2015:http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
• Resource:ThislinksdirectsyoutoanarticleonManagingPainintheGeriatricPatient:
http://jaoa.org/article.aspx?articleid=2093506
• Resource:ThislinksdirectsyoutotheCDCGuidelinesforPrescribingOpioidsinChronicPain:http://dx.doi.org/10.15585/mmwr.rr6501e1
• Resource:ThislinksdirectsyoutoaCDCdocumentonCommonElementsintheaboveguidelines:
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http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-a.pdf
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• Resource:ThislinksdirectsyoutoAMDAClinicalPracticeGuidelinesforPain:
http://www.paltc.org/topic/pain-management
• Resource:ThislinksdirectsyoutoMedscapeOpioidsEquivalentsandConversionshttp://emedicine.medscape.com/article/2138678-overview
• Resource:Thislinksdirectsyoutoan8stepapproachtoexchangingoneopioidagentor
routofadministrationforanotherhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069064/
• Resource:ThislinksdirectsyoutoanopioidDosecalculator:
http://opioidcalculator.practicalpainmanagement.com
• Resource:ThislinksdirectsyoutoanOpioidsconverterprogramonGlobalRPh:http://www.globalrph.com/narcoticonv.htm
• Resource:ThislinksdirectsyoutoUniversityofIowaGeriatricPainAssessmenttools:
https://geriatricpain.org/pain-assessment
• Resource:ThislinksdirectsyoutoAMDAguidelinesonPainassessmentinAssistedLivinghttp://www.assistedlivingconsult.com/issues/01-03/ALC1-3_AMDAPain.pdf
Part2.5.4:PsychotropicsIn2012,CMSlaunchedtheNationalPartnershiptoImproveDementiaCareinNursingHomes.Whentheinitialgoalwasmetin2014,CMSalongwiththeAmericanHealthCareAssociation(AHCA)setnewgoalsforfurtherreduction.Theintentistosafelyreducetheofflabeluseofantipsychoticswhichcanproducenegativeoutcomes.Theprogresstowardthisnewgoalispublished.Therearemanytools,programs,andcontinuingeducationontheuseofpsychotropicsaswellascognitiveassessmenttoolsthatcanbeadministeredbysomeoneotherthanthephysician.
• Resource:ThislinksdirectsyoutotheAmericanPsychiatricAssociationPracticeGuidelineontheUseofAntipsychoticstoTreatAgitationorPsychosisinPatientswithDementia:http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807
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• Resource:ThislinksdirectsyoutoIA-ADAPT–ImprovingAntipsychoticAppropriatenessinDementiaPatientstools:https://www.healthcare.uiowa.edu/IGEC/IAAdapt/pharmacist
• Resource:ThislinksdirectsyoutoColoradoHealthCareAssociationandCenterfor
AssistedLiving:Guidelinesforappropriateuseofantipsychotics:http://cmda.us/wp-content/uploads/2015/11/CHCA-Antipsychotic-Guidelines.pdf
• Resource:ThislinksdirectsyoutotheMontrealCognitiveAssessment(MoCA)Test:http://www.mocatest.org/
• Resource:ThislinksdirectsyoutotheAlzheimer’sAssociationCognitiveAssessmentToolkit:http://www.alz.org/documents_custom/141209-CognitiveAssessmentToo-kit-final.pdf
Part2.5.5:AntimicrobialsImprovingtheuseofantibioticsinhealthcaretoprotectpatientsandreducethethreatofantibioticresistanceisanationalpriorityrequiringdiligent“AntibioticStewardship”.AntibioticStewardshipreferstoasetofcommitmentsandactionsdesignedtooptimizeantibiotictherapywhilelimitingtheadverseeffects.Antibioticsareoneofthemostfrequentlyprescribedmedicationisnursinghomeandstudieshaveshownthat40-75%ofthoseareunnecessary.Theseresourceslistedcanhelpinitiateanantibioticstewardshipprogramaswellastoolsforchoosingempirictherapyanddosing.
• Resource:ThislinksdirectsyoutoASCP’sdedicatedwebsiteonantimicrobialstewardship:http://www.ascp.com/amstoolkit
• Resource:ThislinksdirectsyoutoImplementinganAntibioticStewardshipProgram:
GuidelinesbytheInfectiousDiseaseSocietyofAmericaandtheSocietyforHealthcareEpidemiologyofAmerica:http://cid.oxfordjournals.org/content/62/10/1197.long
• Resource:ThislinksdirectsyoutoAlgorithmspromotingAntibioticStewardshipinLong
TermCare:http://www.jamda.com/article/S1525-8610(15)00728-8/abstract
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• Resource:ThislinksdirectsyoutoCDCCoreElementsforAntibioticStewardshipinLongTermCare:http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
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• Resource:ThislinksdirectsyoutoActionStepsandStrategiestoimplementing
antibioticstewardshipprograminlongtermcare:http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/apxb.pd
f
• Resource:ThislinksdirectsyoutoGlobalRPhInfectiousDiseaseEmpiricTherapy:http://www.globalrph.com/antibiotic.htm
• Resource:ThislinksdirectsyoutoGlobalRPhPathogenicBacteriaResource:
http://www.globalrph.com/bacterial-strains-anaerobic.htm
• Resource:ThislinksdirectsyoutoGlobalRPhAminoglycoside/VancomycinDosingbylevelscalculator:http://www.globalrph.com/dosebylevels.htm
Part2.5.6:NarrowTherapeuticIndexMedicationsLaboratoryresultscanhelpidentifypatientswhomayneeddrugtherapy,andcanbeusedtoevaluateandmonitorapatient’sresponsetoexistingdata.Itcanalsobeimportantinevaluatingthecourseofadisease.Patientsoftendon’thavethisinformation.Approximatelyhalfofpatient’stakinganarrowtherapeuticindexmedicationdonothaveappropriatemonitoring.
• Resource:Thislinksdirectsyouanarticlewithgeneralinformationabouttherapeuticdrugmonitoring:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2687654/
• Resource:ThisisthecitationforaPharmacistletterlabmonitoringchart:(access
requireslogin) PlDetail-Document,LabMonitoringforCommonMedications.Pharmacist’s
Letter/Prescriber’sLetter.June2014.Part2.5.7:Anticholinergic/Sedation/FallRiskMedicationsAnticholinergicsarecommonlyusedtotreatallergies,colds,bladderproblemsandotherailments.Howeverolderadultsareatgreaterrisktoexperienceadverseclinicaloutcomes.ToolstohelpwiththeassessingtheriskinusingincludeAnticholinergicRiskScalesandDrugBurdenIndex.Alongwithassessingtheuseofanticholinergics,therearealsotoolsforfallriskassessments.
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• Resource:Thislinksdirectsyoutoananticholinergicmedicationlistforpatients:
http://www.public-health.uiowa.edu/cert/education/AnticholinergicBrochure.pdf
• Resource:Thislinksdirectsyoutotheanticholinergiccognitiveburdenscale
http://www.agingbraincare.org/uploads/products/ACB_scale_-_legal_size.pdf
• Resource:ThislinkdirectsyoutotheAnticholinergicRiskScale:
http://www.magellanofaz.com/media/757303/magellan_anticholinergic_risk_scale_2014.pdf
• Resource:ThislinksdirectsyoutoanarticleontheDrugBurdenIndex:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166346/pdf/cia-9-1503.pdf
• Resource:ThislinksdirectsyoutotheTimedUpandGoTest(TUG)AssessmentTool:
http://www.rehabmeasures.org/PDF%20Library/Timed%20Up%20and%20Go%20Test%20Instructions.pdf
• Resource:ThislinksdirectsyoutoanotherformatoftheTimedUpandGoTest(TUG)
AssessmentTool:http://www.ocagingservicescollaborative.org/wp-content/uploads/2014/07/Timed-Up-and-Go-TUG.pdf
• Resource:ThisisthecitationfortheTinettiBalanceAssessmentTool:
TinettiME,WilliamsTF,MayewskiR,FallRiskIndexforelderlypatientsbasedonnumberofchronicdisabilities.AmJMed1986:80:429-434
• Resource:ThislinksdirectsyoutotheBergBalanceScale:
http://www.aahf.info/pdf/Berg_Balance_Scale.pdfPart2.5.8:PharmacogenomicsPharmacogenomicsisafieldofresearchfocusedonunderstandinghowgenesaffectindividualresponsestomedication.Thelong-termgoalofthisresearchistohelpselectindividualizedappropriatedrugsanddosages.Therearecurrentlymorethan150medicationsthathavepharmacogenomicinformationincludedontheirlabels.
• Resource:ThislinksdirectsyoutotheNationalInstitutesofHealth(NIH)pharmacogenomicdosingguidelines:https://www.pharmgkb.org/view/dosing-guidelines.do
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• Resource:ThislinksdirectsyoutoafrequentlyaskedquestionspageontheNational
InstituteofGeneralMedicalSciencespage:https://www.nigms.nih.gov/education/Pages/factsheet-pharmacogenomics.aspx
MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.6:ToolstoImproveTransitionsofCareProcessesThissectionisdividedinto5Parts:
• Part2.6.1:CareTransitionsTools• Part2.6.2:MedicationReconciliationTools• Part2.6.3:MedicationManagementTools• Part2.6.4:DeprescribingTools• Part2.6.5:RiskScreeningTools
Part2.6.1:CareTransitionsToolsNationalTransitionsofCareCoalition(NTCC)TheNationalTransitionsofCareCoalition(NTCC)acknowledgesthecomplexityoftransitionsofcare.Poorly-definedresponsibilitiesandineffectivepatienthand-offsbetweencaresettingscanpoorlyimpactcaredeliveryduringthisvulnerabletime.Pooroutcomesmayinclude:wrongtreatment,delayindiagnosis,severeadverseevents,patientcomplaints,increasedhealthcarecostsandincreasedlengthofstay.NTOCCcreatedmanytoolsforhealthcareprofessionalstousetoimprovetransitionsofcarewithinanycaresetting.
• Patientmedicationlisto Helpspatientsandcaregiverskeepprovidersinformedofmostup-to-date
medicationlist• PatientBillofRightsduringtransitionsofcare
o Outlinesinformationandservicespatientsdeserve• “TakingCareofmyHealthcare”consumertool
o Guidespatientsandcaregiversonwhatkindofinformationandquestionstoaskproviders
• Informationalslidedeckandbrochureforconsumerso SummarizeswhattransitionsofcareisandwhatNTCCtoolsareavailable
• Implementationplano Outlinestheconcepts,processand"howto"onimplementingandevaluatinga
TransitionsofCareplan
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• Transitionsofcarechecklisto Helpsenhancecommunicationamonghealthcareproviders,betweencare
settings,andbetweencliniciansandclients/caregivers• Importanceofhealthinformationtechnology(HIT)
o IdentifiesHITproblemsandconsiderationstoimproveoveralltransitionsofcare• Medicationreconciliationessentialelements
o Outlinesimportantconsiderationswhenimplementingamedicationreconciliationprogramtoreducemedicationerrors
• PolicypaperandIssueBriefso DetailsvisionofNTCCtoimprovetransitionsofcareandguidanceforimproving
transitionperformance• Culturalcompetencypaper
o providesinformationaboutculture,culturalcompetence,andstrategiesandresourcestoenhanceprofessionals’capacitytodeliverculturallycompetentservices
SomeofthesepracticaltoolsarealsoavailableinSpanishorFrenchtranslations.
• Resource:ThislinkdirectsyoutotheNTCCtoolsandresourcesavailablefordownload:http://ntocc.org/WhoWeServe/HealthCareProfessionals.aspx
InterventionstoReduceAcuteCareTransfers(INTERACT®)InterventionstoReduceAcuteCareTransfers(INTERACT®)isaqualityimprovementprogramthatincludesclinicalandeducationaltoolstohelppost-acutecareprovidersmanageacutechangeinpatientconditionsandpreventavoidabletransferstothehospital.INTERACT®toolsarecurrentlyavailableforNursingHomes,AssistedLiving,andHomeHealthCarepracticesettings;comingsoonisaversionforACOsHealthSystemsandBundledPayment.Thesesite-specificclinicalandeducationtoolsinclude:
• Qualityimprovementtools• Communicationtools• Decision-supporttoolsforchangeincondition• Advancecareplanningtools
• Resource:Usersarerequiredtocompleteafreelicenseagreementtoaccessthese
tools.ThislinkdirectsyoutotheINTERACT®toolsavailablefordownload:http://www.pathway-interact.com/interact-tools/
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AtlanticQualityImprovementNetwork(AQIN)CareCoordinationInitiativeToolsforPatientsAtlanticQualityImprovementNetwork(AQIN)CareCoordinationInitiativecollectednumeroushelpfultoolsforpatientsandcaregiverstouseduringtransitionsofcare.Theseinclude:
• PersonalHealthRecord(alsoavailableinSpanish)o Formtorecordhealthhistory,medicalconditions,medications,allergies,and
recenthospitalanddoctorvisits• MedicationManagementGoldenRules
o Tipstounderstandandkeeptrackofcurrentmedicationsandchangesmade• AskMe3
o Threekeyquestionsforpatientstoaskproviderswhenreceivingcare• HospitalDischargePlanningGoldenRules
o Tipstocommunicateandstayinvolvedindischargeplanning• ManagingYourCongestiveHeartFailure
o Importantheartfailurefacts
• Resource:ThislinkdirectsyoutotheAQINCareCoordinationInitiativepatienttools: http://atlanticquality.org/initiatives/care-coordination/care-coordination-ny/
IHISTateActiononAvoidableRehospitalizations(STAAR)InitiativeTheIHISTateActiononAvoidableRehospitalizations(STAAR)Initiativewasafour-yearmulti-stateapproachtoimprovetransitionsofcareandreduceavoidablerehospitalizationsthroughfourkeyimprovementareas:
• Performanenhancedassessmentofpost-hospitalneeds• Provideeffectiveteachingandfacilitateenhancedlearning• Providereal-timehandovercommunications• Ensuretimelypost-hospitalcarefollow-up
HelpfultoolsontheIHIsiteinclude:
• STAARoverviewdocuments• How-toguidescustomizedforhospitaltocommunitysettings,hospitaltoSNF,hospital
tohomehealthcare,andhospitaltoclinicalofficepractice• Diagnosticworksheets• Statepolicymakerchecklist• Issuebriefs,webinars,presentations,andvideos
• Resource:ThislinkdirectsyoutotheIHISTAARInitiativetools:
http://www.ihi.org/Engage/Initiatives/Completed/STAAR/Pages/Materials.aspx
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Re-EngineeredDischarge(RED)ToolkitTheRe-EngineeredDischarge(RED)ToolkitwasdevelopedtheBostonUniversityMedicalCenter(BUMC)inconjunctionwiththeAgencyforHealthcareResearchandQuality(AHRQ).REDiseffectiveatreducingreadmissionsandposthospitalemergencydepartmentvisits.Contentsofthisexhaustivetoolkitincludehow-toguidesfor:
• 11stepsforhospitalstoimplementRED• TheAfterHospitalCarePlan• DeliveringREDfordiversepopulations• Post-dischargefollow-up• Monitoringimplementationandoutcomemeasures• Enhancetheroleoffamilycaregivers
• Resource:ThislinkdirectsyoutotheAHRQREDtools:
https://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.htmlPart2.6.2:MedicationReconciliationToolsInstituteforHealthcareImprovement(IHI)MedicationReconciliationContentTheInstituteforHealthcareImprovement(IHI)offersguidanceonprovidingmedicationreconciliationatalltransitionpointstopreventmedicationerrorsthatmayleadtoadverseeventsandharm.IHIdefinesmedicationreconciliationas:“theprocessofcreatingthemostaccuratelistpossibleofallmedicationsapatientistaking…andcomparingthatlistagainsttheadmission,transfer,and/ordischargeorders.”Thegoalofmedicationreconciliationistoensurethatthepatientisreceivingallthecorrectmedicationsandtopreventunintendedchangesoromissionsofmedications.Recommendedchangesforimprovementofmedicationreconciliationprocessesatalltransitionpointsinclude:
• Reconcileadmissionorderswithhomemedicationlistsonadmissiontothehospital• Reconcilemedicationorderswiththemedicationstheyweretakingpriortoadmission
whenpatientsaretransferredfromonecareunittoanother• Reconciledischargeinstructionsandprescriptionswiththemedicationlistcollectedat
admissionandthemedicationadministrationrecord
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Inadditiontotheserecommendations,otherfeaturedcontentonthispageinclude:
• How-toGuide:PreventAdverseDrugEvents(MedicationReconciliation)—RuralHospitalsSupplement
o DevelopedaspartofIHI's5MillionLivesCampaigno Recommendations,implementationandfollow-upmeasuresspecificallytailored
forruralhospitals• MedicationReconciliationReview
o FromtheMayoHealthSysteminEauClaire,Wisconsin,USAo How-to-guideprovidingstep-by-stepinstructionsforhowtoconductareviewto
identifydiscrepancies• MedicationReconciliationFlowsheet
o FromtheMayoHealthSysteminEauClaire,Wisconsin,USAo Tooldesignedfornursestocompletewhilereviewingmedicationorderson
admissionandhelpdeterminenextstepswhenanunreconciledmedicationisidentified
• MedicationReconciliationReview:DataCollectionFormo FromtheMayoHealthSysteminEauClaire,Wisconsin,USAo Anothertoolusedtoaggregateandmonitormedicationreconciliationovertime
asanongoingqualityimprovementeffort• MedicationReconciliationForm
o FromtheBaptistMemorialHospital,Memphis,aparticipantintheIHI’sReducingHighHazardAdverseDrugEventsBreakthroughSeriesCollaborative
o Tooldesignedtotrackapatient’smedicationsuponadmission,transfer,anddischargetodecreasetherateofunreconciledmedications
• MedicationSafetyReconciliationToolkito FromtheNorthCarolinaCenterforHospitalQualityandPatientSafety
• Resource:ThislinkdirectsyoutoIHI“ReconcileMedicationsatAllTransitionPoints”:
http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsatAllTransitionPoints.aspxFreeloginisrequiredtodownloadtoolsonIHIsite.
IHIalsorecommendschangesforimprovementofmedicationreconciliationprocessesinoutpatientsettings:
• Collectandreconcileamedicationlistateachvisitinoutpatientsettingsandhospital-basedclinics
• Includeallmedications(prescriptions,over-the-counter,herbals,supplements,etc.)withdose,frequency,route,andreasonfortaking
• Verifywhetherthepatientisactuallytakingallmedicationsasprescribed• Ifanymedicationchangesaremadeasaresultofthevisit,givethepatientclear
instructiononwhattodoandwhatfollow-upisrequired• Keepanongoingmedicationlistonfileforrecurringoutpatients
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Inadditiontotheserecommendations,otherfeaturedcontentonthispageinclude:
• MedicationListforPatientsandFamilieso FromtheMassachusettsCoalitionforthePreventionofMedicalErrors(in
collaborationwiththeMassachusettsMedicalSociety)• MyMedicationLog
o FromtheNewYorkCityDepartmentofHealthandMentalHygiene(DOHMH),BureauofChronicDiseasePreventionandControl
• Resource:ThislinkdirectsyoutotheIHI“ReconcileMedicationsinOutpatientSettings”
page:http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsinOutpatientSettings.aspxFreeloginisrequiredtodownloadtoolsonIHIsite.
HealthIT.govMedicationReconciliationEHRMeaningfulUseMeasureHealthIT.govsetsmeaningfulusemeasurestohelpprovidersimplementelectronichealthrecords(EHRs).TohelphealthcareprofessionalsmeettheMedicationReconciliationmeaningfulusemeasure,acollectionofresourcesandtoolsareavailabletohelpperformmedicationreconciliationatcaretransitions.SelectreferencesfromCMSandtheNationalLearningConsortiuminclude:
• CMSEHRMeaningfulUseSpecificationSheetforEligibleProfessionalsMedicationReconciliation
• MeaningfulUseCaseStudieso FromtheHealthInformationTechnologyResourceCenter(HITRC)o CaseStudiesthatdescribeproviderexperiencesandlessonslearnedthroughout
EHRimplementationandmeaningfuluse• MedicationReconciliationTool
o FromtheHealthInformationTechnologyResourceCenter(HITRC)o Guideincludingself-assessmentandprocessmodelforhowtomeettheMedical
Reconciliationmeaningfuluse• MedicationDiscrepancyTool(MDT)
o FromTheCareTransitionsProgram,UniversityofColoradoDenver,SchoolofMedicine
o Toolthathelpsidentifyandcharacterizemedicationdiscrepanciesthatarisewhenpatientsaretransitioningbetweencaresettings
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• HowtoCreateanAccurateMedicationListintheOutpatientSettingthroughaPatient-
CenteredApproacho FromConsumersAdvancingPatientSafety(CAPS),AuroraHealthCareo Guidanceforimplementingapatient-centeredapproachtomedicationsafetyin
theoutpatientsetting
• Resource:ThislinkdirectsyoutotheHealthIT.govmedicationreconciliationmeaningfuluseresources:https://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/medication-reconciliation
NorthCarolinaCenterforHospitalQualityandPatientSafetyMedicationSafetyReconciliationToolKitTheNorthCarolinaCenterforHospitalQualityandPatientSafetyMedicationSafetyReconciliationToolKitisanextremelyusefulanddetailedtoolincludedasaresourceonboththeIHIandHealthIT.govreferencesabove.ThisToolKitincludesintroductorymaterialsdetailingthescopeoftheproblemofpoormedicationreconciliationprocesses,particularlyduringtransitionsofcare.TheToolKitthenoutlinesprocessstepstoestablishandimplementamedicationreconciliationprocessandincludessampleprocessmaps,algorithms,andformswhichcanbeusedtodevelopperformanceimprovementmodel.Severalreferences,websitesandexampleprocessesarecitedattheendforfurtherinformation.
• Resource:ThislinkdirectsyoutotheMedicationSafetyReconciliationToolKit:http://www.ncqualitycenter.org/wp-content/uploads/2013/01/MRToolkit.pdf
Part2.6.3:MedicationManagementToolsAmericanMedicalAssociation(AMA)STEPSForwardMedicationAdherenceModuleTheAmericanMedicalAssociation(AMA)STEPSForwardreleasedaMedicationAdherenceModule.Thisonlinemodulecanbecompletedfor0.5CMEanddownloadabletoolsarealsoavailable.Themoduledefinesmedicationnonadherence,howcommonitis,andwhyitisimportanttoaddressbeforeoutliningthefollowingeightstepstoimprovemedicationadherence:
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• Considermedicationnonadherenceasthefirstreasonapatient'sconditionisnotunder
control• Developaprocessforroutinelyaskingaboutmedicationadherence• Createablame‑freeenvironmenttodiscussmedicationswiththepatient• Identifywhythepatientisnottakingtheirmedicine• Respondpositivelyandthankthepatientforsharingtheirbehavior• Tailortheadherencesolutiontotheindividualpatient• Involvethepatientindevelopingtheirtreatmentplan• Setpatientsupforsuccess
Thereaderwillfindtipstoinvolvestaffandpatientsinidentifyingnonadherenceandchangingbehaviors.
• Resource:ThislinkdirectsyoutotheAMAMedicationAdherenceModule:https://www.stepsforward.org/modules/medication-adherence
HealthcareCompliancePackagingCouncil(HCPC)WhitePaperTheHealthcareCompliancePackagingCouncil(HCPC)promotesthebenefitsofunitdosepackagingwithcompliance-promptingfeaturestohelppeopletaketheirmedicationsproperly.TheHCPCreleasedaWhitePaperonImprovingMedicationAdherenceThroughPackaging.ThisWhitePaperdefined“medicationadherence”astheextenttowhichpatientsfollowproviderrecommendationsaboutday-to-daymedicationswithrespecttothetiming,dosage,andfrequency.Theresultsofninestudiesaresharedthatsupporttheirposition.Compliancepackaging(i.e.calendar-oriented,unit-dose,structured,blisterpackaging,remindercards)resultsindecreasedconfusionandmisunderstandingandincreasedadherenceandcompliance.
• Resource:ThisisthecitationfortheHCPCWhitePaper:ImprovingMedicationAdherenceThroughPackaging.HealthcareCompliancePackagingCouncil.Availableat:http://www.hcpconline.org/.AccessedAugust18,2017.
GuideforIdentifyingandResolvingDischargeMedicationAccessibilityProblemsinNewYorkStateTheAtlanticQualityImprovementNetwork(AQIN)QualityImprovementOrganization(QIN)forNewYorkState,SouthCarolina,andtheDistrictofColumbiaprepareda“GuideforIdentifyingandResolvingDischargeMedicationAccessibilityProblemsinNewYorkState”whichoutlinespotentialproblemsandguidanceforresolutiontohelpidentifypotentialdrugtherapyandcommunitypharmacyproblems
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• Resource:ThislinkdirectsyoutotheAQINmedicationaccessibilityproblemsguide:
http://atlanticquality.org/wp-content/uploads/2016/05/508_Doc3-_NYS_Guide_-Access_Problems.pdf
OptimizingDischargeMedicationListsInastudybyBackesetalpublishedinTheConsultantPharmacist,aneedsassessmentperformedcaretransitionspharmacistidentifiedopportunitiestooptimizedischargemedicationlistsinskillednursingfacilities.Thegoalofthispilotstudywastoincreasepatientsafety,reducemedicationerrorsandpreventmedication-relatedhospitalreadmissionsthroughoptimizationofdischargemedicationlists.SomeidealcomponentsofaskillednursingfacilitydischargemedicationlistlistedinTable1include:
• Generateanelectroniclisttominimizehumanerrorrisk• Listbothbrandandgenericmedicationnames• Avoidusingsigcodesandmedicalabbreviations• Provideindicationsforallmedicationsinlaypersonterms• Determineifholdparametersareappropriateandunderstoodbypatientand/or
caregiver• Eliminateunnecessaryprotocolmedications• Considerfontsizeandlayouttomaximizereadability
• Resource:Thisisthecitationforthedischargemedicationlistspilotstudy:
BackesAC,CashP,JordanJ.Optimizingtheuseofdischargemedicationlistsinnursingfacilities.ConsultPharm2016;31:493-9.
Part2.6.4:DeprescribingToolsCanadianDeprescribingNetwork(CaDeN)DeprescribingToolsTheCanadianDeprescribingNetwork(CaDeN)createdseveraldeprescribingguidelinesforreducingorstoppingpotentiallyunnecessaryorharmfulmedications.Theseguidelinestargetthefollowingclassesofmedications:antipsychotics,benzodiazepinesandZ-drugs,protonpumpinhibitors,antihyperglycemics,andantihistamines.Resourcesavailablefordownloadinclude:guidelines,algorithms,informationpamphlets,andlinkstoseveralhelpfulpolypharmacyanddeprescribingresources.Patientdecisionaidsarecomingsoon.
• Resource:ThislinkdirectsyoutotheCaDeNdeprescribingtoold:http://deprescribing.org/resources/
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MedStopperMedStopperisaninteractivewebsitewheretheusercaninputlistsofmedicationsandtheconditionsforwhichmedicationsareusedtogeneratealistofpotentiallyinappropriatemedicationsthatmaybedeprescribed.TheMedStopperPlandisplaysthemedicationsinorderofstoppingprioritywithREDsignifyingthehighestpriority,andGREENthelowestpriority.ThisPlancanbeprinted.Recommendationsfordrugstostoptakeintoconsideration:
• Frailelderlyscale• Potentialforimprovingsymptomsorreducingriskforfutureillnessorcausingharm• WhetheronBeersorSTOPPcriteria• Whethertaperingissuggested
• Resource:ThislinkdirectsyoutotheinteractiveMedStopperwebsite:
http://medstopper.com/GoodPalliative-GeriatricPracticeAlgorithmTheGoodPalliative-GeriatricPracticealgorithmwasdesignedfornursinghomestoreducepolypharmacy.Aseriesofquestionsdeterminewhetherdrugsshouldbecontinuedatthesamedose,reducethedose,stopthedrug,orswitchtoanotherdrug.Thealgorithmassessesif:
• Indicationisvalidandrelevant• Possibleadversereactionsoutweighpossiblebenefits• Drugcausingadversesignsorsymptoms• Anotherdrugissuperior• Dosecanbereducedwithoutsignificantrisk
WhentestedinnursinghomesinIsrael,thealgorithmreducedmortality,hospitalization,andcostwithlowrateofdrugdiscontinuationfailure.
• Resource:ThisisthecitationfortheGoodPalliative-GeriatricPracticealgorithm:GarfinkelD,Zur-GilS,Ben-IsraelJ.Thewaragainstpolypharmacy:anewcost-effectivegeriatric-palliativeapproachforimprovingdrugtherapyindisabledelderlypeople.IsrMedAssocJ2007;9(6):430–4.
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PrioritizationandStoppingMedicationsIn“PrioritizationandStoppingMedications”,Alexanderetal.outlineopportunitiesforprioritizationordiscontinuationofmedicationsbasedondegreeofuncertaintyandreasonforaction.Medicationsmaybediscontinuedwithnoneorminimaluncertaintytocorrectamedicalerror,tosimplifyregimen,whenclinicalbenefitisunlikely,orwhensafeforuseonanas-neededbasis.Withmoderatestakes,adrugdiscontinuationtrialisappropriatebecausebenefithaslikelybeenachieved,abehavioralinterventioncanbesubstituted,orbenefitisunlikelytoberealized.Withhighstakes,carefulprioritizationisnecessary.Real-worldexamplesofpatientsareprovidedforeachriskscenarioabove.
• Resource:Thisisthecitationfortheprioritizationandstoppingmedicationsarticle:AlexanderC,etal.Prioritizingandstoppingprescriptionmedicines.CanadianMedicalAssociationJournal.2006;174(6):1083-4.
MedicationAppropriatenessforPatientsLateinLifeIn“ReconsideringMedicationAppropriatenessforPatientsLateinLife”,Holmesetal.proposedamodelforappropriateprescribingforpatientslateinlifethatconsiders:
• Remaininglifeexpectancy• Timeuntilbenefitwillbeachieved• Goalsofcare• Treatmenttargets
Thegoalofthismodelistoserveasaguidefordiscontinuationorwithholdingoftreatmentsotherwiseindicated,appropriateandrecommendedaccordingtocurrentguidelines
• Resource:Thisisthecitationforthemedicationappropriatenesslateinlifearticle:
HolmesH,etal.Reconsideringmedicationappropriatenessforpatientslateinlife.Archivesofinternalmedicine.2006;166(6):605-9.
Part2.6.5:RiskScreeningToolsTheLACEIndexTheLACEIndexisascoringtoolthatidentifiespatientsathighriskforreadmissionordeathwithin30daysofdischargefromhospital.LACEscoresrangefrom1-19.Ascoreof0–4=Low;5–9=Moderate;andascoreof≥10=Highriskofreadmission.
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LACEstandsfor:
• “L”=lengthofstay• “A”=acuityofadmission(i.e.throughtheEmergencyDepartmentvs.elective
admission)• “C”=co-morbidities• “E”=EmergencyDepartmentvisitswithinthelast6months
ThisIndexcanhelppharmaciststargetandprioritizepatientswhowouldbenefitmostfrommedicationreconciliationandeducationontransition
• Resource:ThislinkdirectsyoutotheLACEindex:http://www.besler.com/lace-risk-score/
