Medication Reconciliation

1
Medication Reconciliation

• Preventing Adverse Drug Events
• One Patient at a Time

2
Todays Schedule

• Medication Reconciliation Introduction
• Break-out session 1 Preparing a Med History
• Best Possible Medication History
• Break-out session 2 Interviewing a patient
• Pre-Admission Verification Form
• Break-out session 3 Med Reconciliation process
• Verification Coding System Medication
  Reconciliation Audit Tool
• Break-out session 4 Medication Reconciliation
  Audit
• Conclusion

3
Safer Healthcare Now!

• A campaign to enlist Canadian healthcare
  organizations in implementing six targeted
  interventions in patient care
• To improve the safety of our healthcare system in
  Canada
• A dynamic approach to quality improvement

4
National Collaborative Effort

• Medication Reconciliation is one of the
• Safer Healthcare Now Initiatives
• Medication Reconciliation
• Improved Care for Acute Myocardial Infarction
• Prevention of Central-Line-Associated Infection
• Rapid Response Teams
• Prevention of Ventilator-Associated Pneumonia
• Prevention of Surgical Site Infections

5
Medication Reconciliation

• A formal process of obtaining a complete and
  accurate list of each patients current
  medications
• At
• Admission, Discharge
• and at all other
• Transitions in Care

6
Transitions in Care
Emergency Room
Critical Care Unit
Inpatient Unit
Rural Facility
Residential Facility
Home Community
Operating Room
Transitional Care Unit
7
Medication Reconciliation

• To prevent Adverse Drug Events (ADEs) by
  implementing medication reconciliation in
  hospitals across Canada
• To eliminate medication discrepancies, at all
  interfaces of care, for all patients
• To ensure patients receive appropriate
  medications while hospitalized
• To improve communications at patient transfer
  points

8
Why Reconcile?

• Chart reviews have revealed over half of all
  hospital medication errors occur at the
  interfaces of care
• Medication errors are one of the leading causes
  of injury to hospital patients

9
The Case for Med Reconciliation

• 2004 Canadian Adverse Events Study
• Drug and fluid related events were the second
  most common type of procedure or event to which
  adverse events were related
• 2004 Study in Canadian Hospital
• 23 incidence of adverse events in patients
  discharged from an internal medicine service
• 72 were medication related

10
The Case for Med Reconciliation

• 2005 Canadian Study
• 151 General Medicine patients
• Prescribed or receiving at least four medications
• Not from an extended care facility
• 53.6 - Patients ? 1 Unintentional Discrepancy
• 38.6 - Potential to cause moderate or severe
• discomfort or clinical
  deterioration
• 46.4 - Omission of regularly used medication

11
Accreditation Responsibilities

• Canadian Council on Health Services Accreditation
  
• Patient Safety Goals Required Organization
  Practices for 2005
• Reconcile the patients medications upon
  admission, and with the involvement of the
  patient
• Reconcile medications with the patient at
  referral or transfer and communicate the
  patients medications to the next provider of
  service at referral or transfer to another
  setting, service, service provider, or level of
  care within or outside the organization

12
Seamless Care

• Desirable continuity of care delivered to a
  patient in the health care system across the
  spectrum of caregivers and their environment
• When moving between levels of care, patients
  drug information is not always transferred to all
  care providers in a timely fashion consequently,
  the patient may not receive the most appropriate
  regimen for their condition of this seamless care
  process
• Medication Reconciliation
• is a key component of the Seamless Care process

13
Medication Reconciliation Process

• Easy as 1-2-3
• Create the most complete and accurate list
  possible of all current medications
• Use this list when writing medication orders
• If using this process after admission orders have
  been written, reconcile and resolve any
  discrepancies

14
Key Benefits

• Prevent inadvertent omission of needed home
  medications
• Prevent failure to restart home medications
  following transfer and discharge
• Prevent duplicate therapy at discharge (result of
  brand/generic) combinations or formulary
  substitutions
• Prevent errors associated with orders having
  incorrect doses or dosage forms

15
Challenges

• No clear owner of med reconciliation process
• May be lack of knowledge and understanding by
  front line practitioners of the importance of
  this function
• No standard process to complete the collection of
  information
• No process to integrate the information obtained
  in the med history to the prescribing process

16
Potential Barriers

• Isnt this physician/nurse/pharmacist job?
• Fear of change
• Just another flavour of the week
• Staff perceive this as additional work
• Reduce the number of caregivers collecting
  medication histories
• Build into usual work process

17
Medication Reconciliation

• Best Possible Medication History
• (BPMH)

18
Best Possible Medication History

• Definition
• A medication history obtained by a
• healthcare professional which includes a
• thorough history of all regular medication
• use (prescription and non-prescription)

19
Information Sources

• Patient best source if patient competent
• Caregiver
• Pharmanet
• Prescription vials/Compliance packaging
• Medication List
• Pharmacy
• Family Physician
• MAR from previous institution

20
Med Rec Process at Admission

• PREPARATION
• Print Pharmanet record
• Addressograph Home Medication Reconciliation form
  
• Determine if patient is capable of providing med
  history

21
Patient Unable to Give Details

• Patient does not know name or details about
  medication
• Obtain a detailed description of medication
• Dosage form (capsule, tablet)
• Strength
• Size
• Shape
• Color
• Markings

22
Caregiver

• Good option if patient is not able to provide
  information
• Obtain information when caregiver is at hospital
  or call at home
• Helpful only if caregiver has knowledge of
  patients medication history and current use

23
Pharmanet Record

• Pharmanet record is a Dispensing History of
  past 15 months
• Limitations
• Does not indicate medications active or
  discontinued
• May indicate compliance if consistent dispensing
  patterns identified
• Will not reflect physician-directed changes made
  at doctor appointments

24
Prescription containers

• Acceptable
• Prescription Vials
• Pharmacy Blister packaging
• Questionable
• Patient packaged cassettes
• Unacceptable
• Evidence of mixing meds in one container
• Unlabelled and Unidentifiable medications

25
Medication List

• A good supporting resource if up-to-date
• Always a good idea to confirm accuracy of each
  item on list with patient
• May be outdated
• Potential for transcription errors
• Educate patients on the importance of bringing a
  Medication List and/or Prescription Vials to the
  hospital

26
Pharmacy

• A good source to obtain Pharmanet record if
  unable to access Pharmanet
• Pharmacist may have additional supporting
  information
• Number of refills left on a prescription
• Compliance problems
• Economic constraints
• Allergy history
• Therapeutic successes, failures

27
Family Physician

• Contact as a last resort to obtain information
• Prescribing information
• Length of therapy
• Indications
• Distribution of samples
• May not be able to identify problems with
  compliance

28
Medication Administration Record

• If patient transferred from another institution
• Long Term Care (LTC)
• Rural hospital to Prince George
• Important to know if Best Possible Medication
  History (BPMH) was done at admission
• Important to record time of last doses

29
Interviewing Patients

• Time commitment Goal 10min
• Introduce yourself and explain your role
• Tell patient you would like to ask him/her some
  questions about his/her medication use
• Ask if this is a good time
• If not, schedule another time

30
Interviewing Patients

• Ask questions until you are confident all
  information is complete and reliable
• Pursue unclear answers until they are clarified
• Use open-ended questions
• What, how, why, when
• Balance with yes/no questions
• Use nonbiased questions
• Do not lead the patient into answering something
  that may not be true
• Ask simple questions
• Avoid using medical jargon

31
Interviewing Patients

• Prompt the patient to remember all medications
• Prescriptions
• Patches, creams, eye drops, inhalers, sample
  medications
• Over-the-counter (OTC) medications
• Herbal and other natural remedies
• Vitamins and minerals
• Non-drug therapy
• Use head-to-toe Review of Systems approach

32
Review of Systems

• HEENT
• Nose, ear or eye drops
• Analgesics used for headache or sinus pain
• Dental products
• Insomnia
• Motion sickness
• Smoking Cessation aids
• Respiratory tract
• Antihistamines
• Decongestants

33
Review of Systems

• GI/GU
• Antacids
• Antiflatulants
• Antidiarrheals
• Laxatives
• Hemorrhoidal preparations
• Vaginal antiinfectives
• Musculoskeletal
• ASA
• Anti-inflammatory agents
• Acetaminophen or combination

34
Review of Systems

• Dermatological
• Psoriatic/Seborrheic
• Antiinfective
• Analgesic topical preparation
• Corns/callus pads or other foot care
• Hematological
• Consider iron, B12, folic acid
• Overall/System-wide
• Vitamins
• Herbal
• Homeopathic or other alternative healthcare
  products

35
If Time Permits

• Indication
• This is the patients version of the indication
• Efficacy
• Tell me how you know this medication is working
  for you?
• Toxicity
• Are there any problems that you are having which
  you think may be caused by this medication?
• If patient says no, probe with a few of the most
  common side effects

36
If Time Permits

• Compliance
• How often do you take this medication?
• Try to verify if cost, dosing frequency, adverse
  effects, or personal beliefs may be an obstacle
• How do you feel your medications impact your
  life?
• Tell me how you feel about medication use, in
  general?
• Inquire about technique and maintenance of
  devices used to facilitate drug delivery or
  monitor drug therapy
• Inhalers and Spacers, BP monitors, Blood glucose
  monitors

37
Medication Reconciliation

• Pre-Admission Medication
• Verification Form

38
Step 1

• True Allergy
• Drug, food, additives, etc
• Immunologically mediated reaction
• Type I Type IV (see Coombs Gell
  Classification)
• Possible Allergy
• Vague/incomplete history of allergic reaction
• Assume worst case scenario
• Include ?
• Intolerance
• Side effects or adverse events
• Predictable response
• NV, GI upset

39
Step 2

• Medication dosing is frequently dependent on
  weight
• Document patients weight in kilograms (kg)
• Actual
• Hospital weigh scale
• Estimate
• Patient report
• Nursing estimation

40
Step 3

• MEDICATION NAME
• Document generic name - chemical name of drug
• If two chemical ingredients, list both
• Avoid use of brand names
• Exception multi-ingredient drugs
• Sofracort framycetin/gramicidin/dexamethasone
• Include full name
• Erythromycin base, Erythromycin estolate
• Avoid use of abbreviations
• Exception ASA - Acetylsalicylic acid

41
Step 3

• STRENGTH
• Include specific information to clearly identify
  what product was dispensed to patient
• Example
• Prescription Ramipril 10mg po daily
• Medication Dispensed Ramipril 5mg capsules

42
Step 3

• FORMULATION
• Acceptable to use abbreviations
• Dosage forms
• Susp- suspension
• Liq liquid
• Tab or Cap tablet or capsule
• Inj injectable
• Special formulations
• EC enteric coated
• SR sustained release

43
Step 3

• Prescription labels will include
• Generic name PLUS
• Manufacturer OR Brand name OR Drug Identification
  Number (DIN)
• Additional Resources
• Pharmacy or CPS
• Drug Product Database http//www.hc-sc.gc.ca/hpb/d
  rugs-dpd/

44
Step 3

• DOSE
• Weight
• mg milligram, g gram, mcg microgram
• Do not use µg confused with mg
• Volume
• ml millilitres, L litres
• Miscellaneous
• International Units
• Do not use IU confused with IV or 10 (ten)
• units
• Do not use U or u confused as zero

45
Step 3

• Route
• po oral
• ng nasogastric
• sc subcutaneous
• im intramuscular
• iv intravenous

46
Step 3

• FREQUENCY
• daily
• Do not use q.d. or QD
• q2days
• Do not use q.o.d. or QOD
• BID, TID, QID
• q4h, q6h, q8h
• 5 times daily

47
Step 3

• Duration
• How long patient has taken med?
• wks, mths, days, doses
• If medication ordered for specific duration
• Indicate time taken in relation to prescribed
  duration
• 2 doses of 14 days
• 17 days of 6 weeks
• 2 months of 6 months

48
Step 3

• Last dose (date/time)
• Use 24hr hospital time
• Month and day is adequate

49
Step 3

• Indication/Comments
• Indication as reported by patient if known
• Adverse events experienced?
• Physician directed patient to reduce dose at last
  office visit
• Non-compliance

50
Step 3

• SPECIAL SITUATIONS
• Documenting PRNs
• Record frequency if there is a pattern
• Include indication and frequency of episodes
• Record in Last Dose column if medication not
  taken in past week

51
Step 3

• SPECIAL SITUATIONS
• Medications given in cycles
• Note date next dose due
• Didrocal kit note where patient is in 90 day
  cycle

52
Step 4

• Moderate use lt 4 x 250ml cups of coffee/day
• Heavy use gt 4 x 250ml cups of
  coffee/day
• Specify details of use below checklist if
  significant to note
• Class of stimulant medications called
  methylxanthines or xanthines
• Theophylline
• Chocolate theobromine
• Caffeine
• Coffee 85mg/250ml (65-120mg)
• Tea 40mg/250ml (20 110mg)
• Cola 25mg/250ml (20-40mg)
• Wake up 100mg caffeine tablets
• Anacin, Excedrin, Midol, Tylenol 1

53
Step 4

• Alcohol effects the metabolism and effect of many
  medications
• Social
• Drinks alcoholic beverages in moderation, chiefly
  when socializing
• Abuse
• Women or Elderly gt65yrs gt 7 drinks per week or
  gt 3 drinks per occasion
• Men gt 14 drinks per week or gt 4 drinks per
  occasion
• One drink
• 12-oz bottle of beer (4.5 alcohol) or
• 5-oz glass of wine (12.9 alcohol) or
• 1.5-oz of 80-proof distilled spirits.

54
Step 4

• Nicotine is a drug that can interact with other
  medications
• Former smoker
• Note quit date
• Current
• Note number of cigarettes or packs smoked per day
• Note if smoking cigars

55
Step 4

• Recreational
• Illicit drug use
• Marijuana, cocaine, crystal meth, heroine
• Prescription or non-prescription use
• Narcotics - Tylenol 1, Amphetamines,
  Benzodiazepines
• Interviewing Tips
• A lot of people are using recreational drugs
  these days. These drugs have a possibility of
  interfering with the medications you will be
  receiving in the hospital. Have you tried any?
  Are you currently using any?

56
Step 4

• Influenza lt 1yr
• Pneumococcal lt 5yr
• Tetanus/Dipth lt10yr
• Hep B x 3
• Hep A x 2
• MMR x 2
• Meningococcal
• Varicella x 2

57
Step 5

• Indicate Source of Information
• Ideal to interview patient
• Limitations if patient
• Confused
• Does not speak English
• Too ill to interview
• A good idea to document Family Physician,
  Pharmacy and Caregiver contact info in the event
  more information is needed later

58
Step 6
DOCUMENTED BY
  Alana Froese
1530hr May 12/06 Nurse/Pharmacist/Techn
ician Signature Date/Time

• Sign your name
• Record date and time
• Insert into patient chart
• beginning of Orders section

59
Physician Ordering Features

• Physician reviews Pre-Admission Medication list
• Continues
• Discontinues
• Changes
• Verification Codes
• Pharmaceutical Care Process
• Eight Drug Related Problems (DRPs)
• A quick way for physicians to indicate reasons
  for intentional changes to therapy
• Physician signs and dates order

60
Order Processing Features

• Unit clerk processes orders and transcribes to
  MAR
• uses yellow highlighter or initials in right
  column to indicate order has been processed
• RN initials right column to indicate Unit Clerk
  has processed order and transcribed to MAR
  appropriately
• Check Faxed to Pharmacy to indicate order has
  been sent to Pharmacy

61
Final Touches
ST ST
62
Medication Reconciliation

• Verification Coding System

63
Verification Code 1

• INDICATION
• 1.1 Patient has a diagnosed problem which
  requires a drug therapy
• New symptoms or indication revealed/presented
• 1.2 Preventative drug required
• Taking a drug for valid indication, but this drug
  causes side effects which require prophylactic
  therapy
• 1.3 Synergistic drug required
• Requires synergistic drug therapy to potentiate
  effect of current drug therapy

64
Verification Code 2

• NO INDICATION
• 2.1 No clear indication for drug use
• Improvement of disease state
• Receiving drug chronically which was intended for
  acute condition
• Recreational use, addiction/dependence
• Condition can be more appropriately treated by
  non-drug therapy
• 2.2 Receiving a drug to treat an avoidable ADR
• 2.3 Inappropriate duplication of therapeutic
  class or active ingredient

65
Verification Code 3

• DOSE TOO LOW/DURATION TOO SHORT
• 3.1 Drug dose too low (sub-therapeutic)
• 3.2 Dosage regime not frequent enough
• 3.3 Duration of treatment too short

66
Verification Code 4

• DOSE TOO HIGH/DURATION TOO LONG
• 4.1 Drug dose too high (dose dependent toxicity)
• 4.2 Dosage regime too frequent
• 4.3 Duration of treatment too long

67
Verification Code 5

• WRONG DRUG
• 5.1 Inappropriate drug
• Inappropriate drug or dosage selection
• More cost effective drug available
• Drug therapy is known to be ineffective for this
  indication
• Drug therapy is effective for this indication,
  but not effective in this patient for unknown
  reasons
• 5.2 Inappropriate drug form
• Cannot take the drug product (swallow, taste,
  administration)
• 5.3 Contraindication for drug (incl. pregnancy/
  breastfeeding)

68
Verification Code 6

• NON-COMPLIANCE
• 6.1 Patient is not compliant
• Drug underused, overused or abused
• Patient has difficulties reading/understanding
• 6.2 Drug not taken/administered at all
• Patient unable to use drug/form as directed
• Patient unwilling to carry financial costs
• Prescribed drug not available
• 6.3 Wrong drug taken/administered
• Prescribing error
• Dispensing error (wrong drug or dose dispensed)
• Administration error (by patient/caregivers)

69
Verification Code 7

• ADVERSE EVENT
• 7.1 Side effect suffered at a therapeutic dose
  (non-allergic)
• 7.2 Side effect suffered at a therapeutic dose
  (allergic)
• 7.3 Toxic effects suffered

70
Verification Code 8

• DRUG INTERACTION
• 8.1 Potential or actual Drug/Drug interaction
• 8.2 Potential or actual Drug/Food interaction
• 8.3 Potential or actual Drug/Laboratory
  interaction

71
Medication Reconciliation

• Medication Reconciliation
• Audit Tool

72
Purpose

• To collect data and measure reduction in
  discrepancies between home medication list and
  admission orders

73
Discrepancies

• Intentional
• Physician has made an intentional choice to add,
  change, discontinue a medication
• Choice is clearly documented
• Undocumented Intentional
• Physician has made an intentional choice to add,
  change, discontinue a medication
• Choice is not clearly documented
• Unintentional
• Physician unintentionally changed, added, or
  omitted a medication the patient was taking prior
  to admission

74
Measurements

• Mean Undocumented Intentional Discrepancies
• of undocumented discrepancies
• of patients
• Goal Reduce the rate of undocumented intentional
  discrepancies at admission by 75 in 1 year

75
Measurements

• Mean Unintentional Discrepancies
• of unintentional discrepancies
• of patients
• Goal Reduce the rate of unintentional
  discrepancies at admission by 75 in 1 year

76
Measurements

• Medication Reconciliation Success Index
• of NO discrepancies of documented
  intentional discrepancies X100
• of NO discrepancies
  total of ALL discrepancies
• Goal To increase the effectiveness of the
  medication admission reconciliation process over
  time

77
Recording

• Document details of discrepancies
• Med Reconciliation form
• Patients Hospital record
• Indicate if OTC medication
• Definition A medication not prescribed by a
  physician
• OTC medication discrepancies will not be reported
  to National Safer Healthcare Now campaign
• Resolve or transfer to pharmacist for follow up
• Record if discrepancies were resolved on
• Med Reconciliation form
• Recorder to sign form

78
Recording

• Record Admission Date/Time
• Defined as time patient was designated to be
  admitted to hospital
• Not Emergency admission time
• Reconciliation Date/Time
• Perform within 24 hours after admission
• Implementation Stage
• Baseline before changes to process
• Early Implementation after changes to process
  made by a select team
• Full Implementation when medication
  reconciliation process is integrated by all staff
  on designated ward

79
Investigators Role

• Lead investigator will collect audit forms
• Will be responsible for
• Completing Discrepancy Totals on forms
• Calculating reporting measurements to National
  Safer Healthcare Now Campaign
• Reporting findings internally

80
Medication Reconciliation

• Coming to a Hospital Near You!

81
NH-Wide Implementation

• Initial testing sites
• Prince George
• Quesnel
• Dawson Creek
• Burns Lake
• Goal To standardize the Medication
  Reconciliation process
• Continue to spread implementation to all
  healthcare settings in Northern Health

82
Just Do It!

• PUT THEORY INTO PRACTICE
• ESTABLISH STANDARD PROCESS
• PROMOTE MEDICATION SAFETY
• BEGIN IMPLEMENTATION TODAY

83
Leading the Way

• You are the Trail Blazers
• Role Models, Mentors, Educators
• Promote cultural change
• Lead by Example
• Collaborate
• Demand Excellence
• Do not Compromise

84
Building it into the Process

• The names of the patients whose lives we save
  can never be known. Our contribution will be what
  did not happen to them. And, though they are
  unknown, we will know that mothers and fathers
  are at graduations and weddings they would have
  missed, and that grandchildren will know
  grandparents they might never have known, and
  holidays will be taken, and work completed, and
  books read, and symphonies heard, and gardens
  tended that, without our work, would never have
  been. Donald M. Berwick, MD, MPP
• President and CEO
• Institute for Healthcare
  Improvement

85
Accomplishing the Impossible
means only that the boss will add it to your
regular duties Doug Larson