Medication Reconciliation at Peach Arch Hospital

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Medication Reconciliationat Peach Arch Hospital

• Pam McCarthy RN
• October 4, 2006

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What is Medication Reconciliation?

• Medication Reconciliation is the formal process
  of obtaining a complete and accurate list of each
  patients home medications AND the act of
  reconciling the list to the physicians orders
  written on admission, transfer and at discharge.
  
• Any variance from the home medications are
  resolved and documented.
• Goal is to prevent adverse drug events (ADE)

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Medication Reconciliation

• Obtaining a complete and accurate, Best Possible
  Medication History (BPMH) is a collaborative
  effort involving

Patient
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What is Safer Healthcare Now!

• Safer Healthcare Now! campaign is aimed at
  reducing preventable complications and deaths in
  Canadian hospitals.
• Patterned after the 100K Lives campaign
  established by the US Institute for Healthcare
  Improvement
• The campaign consists of six targeted,
  evidence-based strategies to improve patient care
• Fraser Health has signed on to fully participate
  in the campaign

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Where are we in Fraser Health?

• Identification of ER Pilot Site Team co-leads
• Dr. Kerry Yoshitomi
• Jodi Krotje
• Interdisciplinary ER Team
• ER Physician Dr. J. Hendry
• ER RN Pam McCarthy
• ER CNE - Jennifer McDuff
• ER Pharmacist Dr. Susan Buchkowski
• QI/Patient Safety Consultant Barb
  Saunders/Marianne Southwell
• Medication Safety Coordinator Janice Munroe

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Where are we in Fraser Health?

• Identification of Medicine Pilot Site Team
  co-leads
• Dr Antonio Benitez
• Carole Kisielius
• Interdisciplinary Team
• Vicki Reilly RN
• Caroline Mojak CNE
• Gerry Watts Pharmacist
• QI/Patient Safety Consultant Barb
  Saunders/Marianne Southwell
• Medication Safety Coordinator Janice Munroe

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Pilot Team - Implementation Plans

• Process flow mapping
• Identify resources required to complete
• Budget submission
• Develop processes and forms
• Multiple PDSA cycles following Quality
  Improvement principles and application of the
  Collaborative Learning Model

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A different approach

• Improvement methodology rather than research
  methodology
• Small tests of change rather than controlled
  trials
• Small sampling rather than randomized formal
  sampling
• Concurrent collection of key data rather than
  retrospective comprehensive evaluation
• Learning rather than judgement

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What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Adapted from The Institute for Healthcare
Improvement
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What Changes Will We Make - The PDSA Cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who,
• what, where, when)

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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What are we trying to accomplish?

• Write a clear aim statement
• Define the population
• Define boundaries/limitations
• The aim statement is meant to keep the team
  focused

Adapted from The Institute for Healthcare
Improvement
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What is the goal of Medication Reconciliation?

• Reduce adverse drug events (ADE) by reconciling
  medication orders at all key transition points in
  order to
• Eliminate undocumented intentional discrepancies
• Eliminate unintentional discrepancies
• Increase the number of medication orders that are
  reconciled (success index)

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How will we know that a change is an improvement?

• All intentional discrepancies are documented -
  initially to improve by 75 from baseline
• All unintentional discrepancies are eliminated -
  initially to improve by 75 from baseline
• Medications are reconciled initially to
  increase to 90 of ordered medications

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Medication ReconciliationBaseline Data

• 20 patients reviewed at Peace Arch Hospital in
  December 2005
• 134 medications ordered gt average of 6.7 meds
  per patient
• Per patient, 0.9 (13) orders were changed
  without a documented reason. The lack of
  documentation could result in an inappropriate
  correction or error.
• There were 1.45 (22) unintentional discrepancies
  per patient. These are medication errors.
• Calculated Success Index 65 ie. 35 of the
  written orders are in error or have the potential
  to result in error

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Testing on a Small Scale

• Conduct the test
• in one unit, with one nurse, physician etc.
• with a small number of patients
• over a short time period

Adapted from The Institute for Healthcare
Improvement
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AIMDecrease undocumented intentional
discrepancies and unintentional discrepancies by
75 of baselineIncrease the Success Index to 90
Reduced Adverse Drug Events
Adapted from The Institute for Healthcare
Improvement
DATA
Cycle 10 Patient/Family complete form _at_ bedside
if on 3 or gt meds
Cycle 9 Patient/Family complete form _at_ bedside
Cycle 8 Patient/Family complete form _at_ triage if
on 3 or gt meds
Cycle 7 Patient/Family complete form _at_ triage
Cycle 6 Bedside nurse using the form on admitted
patients on 3 or more meds
Cycle 5 Bedside nurse using the form on admitted
patients on meds
Forms and processes to support Med Rec
Cycle 4 Bedside nurse using the form on all
admitted patients
Cycle 3 BPMH form at triage for patients on 3 or
gt medications
Cycle 2 BPMH form at triage for patients only if
on medications
Cycle 1 BPMH form at triage for all patients
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Using Data The Run Chart

• Evaluate data regularly (15 audits/month)
• Continue to run PDSA cycles
• Evaluate what is happening in the process
• Regularly report results to
• Frontline staff
• Site team members
• FH Medication Reconciliation Steering Committee
• FH SHN Steering Committee/Quality Council
• SHN Western Node

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Annotated Run Chart- PAH
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Annotated Run Chart PAH
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Annotated Run Chart PAH
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Pilot Team Current Status at PAH

• ER Go-live date was August 21
• Continue PDSA cycles to resolve process and form
  issues
• Targeted chart audit to provide feedback to ER
  staff
• Established Medicine team
• Joint ER and Medicine team meetings to share
  learnings

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Items for consideration

• Support to continue audits to ensure that the
  practice is sustained over time and that the
  improvement holds
• Site Team evolution as spread occurs
• Spread to other FH sites multiple vs single?
• Community involvement phase I or II or??