SHNCAPHC Paediatric Medication Reconciliation Orientation and Training Workshop August 9, 10, 2005

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SHN-CAPHC Paediatric Medication Reconciliation
Orientation and Training WorkshopAugust 9, 10,
2005

• Margaret Colquhoun
• Project Leader ISMP Canada

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Agenda

• About ISMP Canada
• Partnership with SHN, CAPHC
• The Canadian Getting Started Kit
• What is in it?
• What is different?
• Next Steps

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ISMP Canada Vision

• Realizing an international network that shares
  recommendations for the prevention of medication
  error-induced patient injuries.

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ISMP Canada Mission

• Committed to the safe use of medication through
  improvement in drug distribution and drug
  delivery system design.
• Collaborate with healthcare practitioners and
  institutions, schools, professional
  organizations, pharmaceutical industry and
  regulatory government agencies to provide
  education about adverse drug events and their
  prevention

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ISMP Canada

• Voluntary incident reporting
• Errors, near-misses and hazardous situations
• Confidential
• Non-punitive
• Front-line practitioners provide detailed,
  unrestricted information on incidents
• Analysis recommendation of prevention
  strategies

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Publications Newsletters
Now available on ISMP Canadas website
Medication Safety Alert! (biweekly)

• ISMP Canada Safety Bulletin (monthly)

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Bulletin Excerpt
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How Error Reports are received

• website www.ismp-canada.org
• e-mail info_at_ismp-canada.org
• Phone 1-866-54-ISMPC 47672 or
• 416-480-4099.
• ISMP Canada guarantees confidentiality and
  security of information received. ISMP Canada
  respects the wishes of the reporter as to the
  level of detail to be included in publications.

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ISMP Canada Programs

• CMIRPS (Canadian Medication Incident Reporting
  and Prevention System)
• 3 partners
• ISMP Canada,
• Canadian Institute for Health Information (CIHI)
  
• Health Canada

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ISMP Canada Programs

• Safer Healthcare Now!
• 12 month Fellowship program
• Hospital Consultations
• CPSI/ISMP Canada Root Cause Analysis (RCA)
  workshops
• Failure Mode and Effects Analysis (FMEA)
• Education/ Presentations

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ISMP Canada Programs

• Canadian Council on Health Services Accreditation
  (CCHSA) Collaborative Patient Safety Project
• New standard 14.5 - MSSA
• Review and revisions of standards related to
  medication use
• Collaborative workshops

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ISMP Canada Programs

• Medication Safety Support Service Ontario
• Potassium Chloride
• Narcotics (opioids)
• Long term care
• EMS
• Error Reporting
• Alberta Medication Safety Collaborative
• MSSA British Columbia

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Canadianizing the Medication Reconciliation
Starter Kit

• Partnership with CPSI
• The Process
• Multidisciplinary review
• Canadian references and experiences
• Canadian tools
• A new Canadian conceptual framework
• CAPHC conference feedback a work in progress

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Getting Started with Medication Reconciliation
the Kit

• Contents
• The goal
• The case
• What is medication reconciliation?
• Potential impact
• Why there is a problem
• Model for improvement
• How to conduct medication reconciliation

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Other Contents

• Guide
• Potential barriers
• Tips for data collection
• Tips for interviewing patients
• Data collection tools
• Data reporting tools
• Sample reconciliation tools
• Sample policies and procedures
• Online forms
• Staff education
• Suggested literature

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The Goal

• The goal of medication reconciliation is to
  eliminate
• Undocumented intentional discrepancies
• Unintentional discrepancies
• Potential Harm to patients

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The Case

• 2004 study, Forster et.al., found 23 incidence
  of adverse events in patients discharged from
  internal medicine service, of which 72 were
  ADEs
• 53.6 of 151 patients (gt4 meds) had at least
  one unintended discrepancy. 38.6 had potential
  to cause moderate to severe discomfort or
  clinical deterioration

REF Forster AJ, Clark HD, Menard A, Dupuis N,
Chernish R, et. al., Adverse events among medical
patients after discharge from hospital. Can Med
Assoc J. 2004170(3)345-349. Cornish PL,
Knowles SR, Marcheso R, Tam V, Shadowitz S,
Juurlink DN, Etchells EE. Unintended medication
discrepancies at the time of hospital admission.
Arch Intern Med. 2005165424-429.
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The Case Contd

• 2001 UK Audit Commission report A Spoonful of
  Sugar states ..at some hospitals visited 30
  of patients had incorrect or incomplete medicines
  or allergies recorded on admission

REF Audit Commission for Local Authorities and
the National Health Service in England and Wales.
A Spoonful of Sugar -Medicines Management in NHS
Hospitals. London, England The Audit Commission,
2001. Available at http//www.auditcommission.
gov.uk/reports/AC-REPORT.asp?CatIDenglish5EHEALT
HProdIDE83C8921-6CEA-4b2c-83E7- F80954A80F85.
Accessed 23 July 2005.
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What is Medication Reconciliation ?

• a formal process of obtaining a complete and
  accurate list of each patients current home
  medications including name, dosage, frequency
  and route and comparing the physicians
  admission, transfer, and/or discharge orders to
  that list. Discrepancies are brought to the
  attention of the prescriber and, if appropriate,
  changes are made to the orders. Any resulting
  changes in orders are documented.1

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Potential Impact of Medication Reconciliation

• A series of interventions, including medication
  reconciliation, decreased the rate of medication
  errors by 70 and reduced adverse drug events by
  over 15.1
• Initiating reconciling process by obtaining
  medication histories for the scheduled surgical
  population reduced potential adverse drug events
  by 80 within three months of implementation.2
• Successful medication reconciling process reduces
  work and re-works associated with the management
  of medication orders. After implementation,
  nursing time at admission was reduced by over 20
  minutes per patient. The amount of time
  pharmacists were involved in discharge was
  reduced by over 40 minutes.3
• 1 Whittington J, Cohen H. OSF Healthcares
  journey in patient safety. Qual Manag Health
  Care. 200413(1)53-59.
• 2 Michels RD, Meisel S. Program using pharmacy
  technicians to obtain medication histories. Am J
  Health-Sys Pharm. 2003601982-1986.
• 3 Rozich JD, Howard RJ, Justeson JM, Macken PD,
  Lindsay ME, Resar RK. Standardization as a
  mechanism to improve safety in health care
  impact of sliding scale insulin protocol and
  reconciliation of medications initiatives. Jt
  Comm J Qual Saf. 200430(1)5-14.

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Why Is there a Problem?

• Low priority
• No clear owner
• Lack of understanding of potential impact
• No established criteria
• No standardized process
• Patients do not know how important it is to know
  what they are taking

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Model for Improvement

• Set clear aims
• Establish measures to identify whether a change
  is an improvement
• Identify changes that are likely to lead to
  improvement
• PDSA cycle

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How Do We Do This?

• Secure Leadership Commitment
• Form a team
• Collect Baseline Data
• Set Aims (Goals and Objectives)
• Start with a Pilot Project Begin to Learn How
  to Reconcile Medications
• Continue to Implement Medication Reconciliation,
  Test Results and Spread
• Evaluate

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1. Leadership

• Establish clear goals
• Identify Executive Sponsor
• Identify and remove potential barriers
• Allocate dedicated resources
• Develop a framework for monitoring and evaluation
  
• Communicate continuously with front line staff
  regarding progress and successes at critical
  stages of the project
• Consider incentives or special recognition

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2. The Team

• Executive sponsor
• Clinical leaders physicians, nursing and
  pharmacy staff
• Front line caregivers from key settings of care,
  and from all shifts
• Representatives from patient safety (e.g. Patient
  Safety Officer, Quality Improvement/Risk
  Management, Patient Representatives, Pharmacy and
  Therapeutics committee)

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3. Collecting Baseline Data

• Review medication histories and admission
  medication orders on 10 - 20 current cases over
  the course of one week.
• Let the normal process of taking a medication
  history (primary medication history (PMH) occur.
• Get a best possible medication history (BPMH).
• Compare the admission medication orders (AMO)
  with the best possible medication history (BPMH)
  to identify any discrepancies.
• Clarify discrepancies with the ordering or most
  responsible physician
• Identify Unintentional Discrepancies (the
  potential for patient harm) and Undocumented
  Intentional Discrepancies

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Conceptual Framework

• PMH primary medication history
• AMO admission medication orders
• BPMH best possible medication history
• Discrepancies intentional unintentional,
  documented and undocumented

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Intentional Discrepancy

• An intentional discrepancy is one in which the
  physician has made an intentional choice to add,
  change or discontinue a medication and their
  choice is clearly documented. This is considered
  to be best practice in medication
  reconciliation.

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Undocumented Intentional Discrepancy

• An undocumented intentional discrepancy is one in
  which the physician has made an intentional
  choice to add, change or stop a medication but
  this choice is not clearly documented.

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Example of an Undocumented Intentional Discrepancy

• A patient on a maintenance dose of atenolol for
  hypertension was admitted for surgery.  The
  surgeon did not order atenolol on admission, due
  to concerns about perioperative hypotension
  however, the reason for not ordering atenolol was
  not documented in the medical record.  The
  patient was discharged on the third postoperative
  day and was given a discharge prescription that
  did not include atenolol.  The patient was unsure
  whether to resume treatment with atenolol at home
  and called his family physician for advice.

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An Unintentional Discrepancy

• An unintentional discrepancy is one in which the
  physician unintentionally changed, added or
  omitted a medication the patient was taking prior
  to admission.

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Unintentional discrepancies are medication errors
than can lead to ADEs.

• They can be reduced by ensuring good training of
  nurses/MDs/pharmacists at obtaining in-depth
  medication histories and by wisely involving
  clinical pharmacists to identify and reconcile
  these discrepancies.

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Example of an Unintentional Discrepancies

• Patient on multiple medications admitted with
  stroke.  Admission medication orders included
  propafenone, based on information in a recent
  volume of the patient's chart.  A follow-up
  interview with the patient's family and community
  pharmacy revealed that this medication had been
  discontinued one month prior to admission. 
  Propafenone was stopped.

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Baseline Data Concurrent Chart Audits

• Identifies patients at hazard while at hazard
  and immediate actions for improvement can be
  made.
• Measures of success
• Mean undocumented intentional discrepancies
• Mean unintentional discrepancies
• Rate of Potential Harm Averted (Percent)

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4. Set Aims

• E.g. Conduct a BPMH on all patients with greater
  than 5 medications within 24 hours of admission
  and reconcile discrepancies
• Reduce the percentage of unintentional
  discrepancies at admission on pilot unit by 75
  in 3 months

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5. Pilot Projects

• Admission
• High level process map
• Test a medication reconciliation form
• Modify form
• Continue testing and changing

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6. Roll Out

• Pilot Test PDSA
• Implement
• Define patient groups
• Define criteria
• Test tools
• Spread

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7. Evaluate

• Errors unintentional discrepancies
• Documentation Accuracy
• Potential Harm Averted
• Run Charts
• Documented Intentional should become THE NORM

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Mean Number of undocumented intentional
discrepancies

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Mean Number of unintentional discrepancies
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Rate of Potential Harm Averted (Percent)
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Run Charts

• Improvement takes place over time.
• Run charts are graphs of data over time and are
  one of the single most important tools in
  performance improvement.

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Benefits of Run Charts

• Help improvement teams formulate aims by
  depicting how well (or poorly) a process is
  performing
• Help in determining when changes are truly
  improvements by displaying a pattern of data that
  you can observe as you make changes
• Give direction as you work on improvement and
  information about the value of the particular
  changes

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Run Chart Example
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Tips

• Involve patients and families!!!!
• Develop criteria for patients who should receive
  BPMH

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Medication Reconciliation

• Not complicated
• Will take
• time,
• resources,
• Commitment
• CAPHC, ISMP Canada, Safer Healthcare Now! will
  focus on
• Sharing
• Learning

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• Together we will reduce potential adverse
  outcomes of care related to medications