Learn best practices based on literature and how to perform a complex and accurate medication history. Recognize gaps/inconsistencies in systems that impede medication reconciliation and identify next steps in improving current medication reconciliation within your own practice.
Speaker:
Mary Pat Friedlander, MD
Lawrenceville Family Health Center
Pittsburgh, PA
2.
Neither I nor any immediate family member
(parent, sibling, spouse or child) has a financial
relationship with or interest in any commercial
entity that may have a direct interest in the
subject matter of this session.
3.
Define the components of an accurate
medication reconciliation
Recognize gaps and inconsistencies in the
medication reconciliation process
Identify next steps in your practice to improve
medication reconciliation
4.
Poor communication at transition
points led to 50% of the medication
errors and 20% of adverse drug
reactions
Variability in medications patients
take prior to admission and admit
orders up to 70%
5.
Discharge drug summaries
66% one inconsistency
32% potentially harmful drug omissions
17% unjustified medications
16% were potentially harmful
6.
2005-National Patient Safety Goal #8
2009-Announcement of need for change
8A-process must exist for comparing current meds
with those ordered while in the organization
8B-complete list of medications must be
communicated to the next provider on service or
outside the organization and a complete list given to
patient at discharge.
Many organizations came together
2013—NPSG #3.06.01
7.
Improve the safety of using medication
1. Label all medications, medication containers, and
other solutions on and off the sterile field in
perioperative and other procedural settings
2. Reduce the likelihood of patient harm associated
with the use of anticoagulant therapy
3. Maintain and communicate accurate patient
medication information.
8.
Record and pass along correct
information about a patient’s medicines.
Find out what medicines the patient is
taking. Compare those medicines to new
medicines given to the patient. Make
sure the patient knows which medicines
to take when they are at home. Tell the
patient it is important to bring their upto-date list of medicines every time they
visit the doctor.
10. PCMH 3: Plan and Manage
Care
• Identify patients
with specific conditions
including high-risk
or complex, behavioral
health
• Care management
– Pre-visit planning
– Progress toward goals
– Barriers to treatment goals
• Reconcile medications
• E-prescribing
Meaningful Use Criteria
• Clinical decision support
• Medication reconciliation
with transitions of care
• E-prescribing
• Drug-drug, drug-allergy
checks
• Transmit prescriptions
using EHR
• Drug-formulary checks
11.
Medication reconciliation post-discharge:
percentage of discharges from January 1
to December 1 of the measurement year
for members 66 years of age and older for
whom medications were reconciled on or
within 30 days of discharge.
12.
Process of identifying the most accurate list of
all medications a patient is taking
Name, dosage, frequency and route
Use this list to provide correct medications for
patients anywhere within the health care
system
Compare the patient’s current list against the
admission, transfer or discharge orders
15.
Engage the patient
Engage the caregivers
Ask open ended questions
Have patient bring in ―bag of meds‖
Provide a list of meds
Date the list
16.
Use systematic approach
Ask about allergies
Medication allergies
Reactions
Other allergies
Prescriptions
Do you take anything prescribed every day
How many times a day
Do you take anything on as needed basis
Do you take anything prescribed by other provider
17.
Prescriptions
Do you use any patches or creams
Do you receive any injections at the doctor’s office
Do you take any sample medications
OTCs
Do you take any medications that don’t need a
prescription
What do you take when you get sick? Heartburn?
Menstrual cramps? Headaches?, etc.
18.
Herbals/Natural/Vitamins
What vitamins do you take
What herbal medications do you take
What natural supplements do you take
What dietary supplements do you take
Review Medical Problems list
Do you take anything for your high blood pressure?
diabetes? your heart? thyroid?, etc.
19.
Medication Concerns
Tell me about missed doses in the last week
What problems do you have with your meds?
What concerns do you have about side effects
Tell me about any difficulty paying for your meds?
Tell me about any medications that you don’t think
are helping you?
Medications with incomplete information
Who, what, where, when and why?
21.
ER, tests, same day surgery, procedure
Current Meds
Let know of any changes or need to
discontinue medication
22.
Collect Medication list/Verify a previous list
Two Questions
Did any current medication change?
Have any new prescriptions been added?
Give clear instructions on the change
Have in writing
Have patient teach back the new change
23.
Who owns the process?
No standardized process for home med list
Doctors won’t order meds they did not give
Time
Just another form
Patients without knowledge of meds
Doctor, nurse, MA, pharmacist
Blue pill, heart pill, ―I don’t know, don’t you know‖
Link of Current Med list to Order screen
24.
Very little data to compare
Time/Labor intensive
Different processes/solutions
Hiring discharge advocate/pharmacist
Hard to study
Different EMR systems
Many studies outside of US
25.
Patient Centered
Easy to complete for all
Home list is available when prescribing meds
Patient gets up-to-date list
All providers are aware of changes
26.
Agree on definitions
Get buy in from leadership
No one size fits all approach
Limit number of processes
Defects found are part of the larger system
Inpatient vs. surgery vs. ER vs. outpatient settings
Not by-product of process
Specify who is responsible
Hold them accountable
27.
Develop a process
May include forms
Establish communication
Across spectrum of care
Nursing homes, Long term care facilities, clinician
offices, specialists, home health agencies
Don’t do in committee—Engage stakeholders
Use Model for Improvement Strategy
PDSA, etc.
28.
Process should identify failure of system and
help correct the failure
Train staff
Develop guides for patients/staff
Involve patients in design of medication list
card—can there be universal card in your area?
If form not used in intended way
Ask why? Does form need to be changed?
Does their need to be more training
29.
Do a small pilot program
Start in one clinical area
Use specific high risk patients
Age >65
4+ chronic medications
High risk medications
3+ chronic medical conditions
30. Inpatient studies
1.
70% decrease in medication errors
15% decrease in adverse drug events
2. Decrease amount of time spent to rework
3 Discharge Advocate and pharmacy
phone calls decreased 23.8% decrease in
hospital utilization 30 days post discharge
31.
Little data on outpatient
Clinical pharmacists with most data
Meet with patients in the office
Reconcile meds
Saved money
Billing by pharmacist?
32.
Depart Process
Med Rec at admission, transfer, discharge
―Patient Friendly‖ Summary given
Email generated to PCP (if in system)
Residency Practice
PharmD Resident calls patient at d/c
Reviews meds/arranges f/u
33.
34.
35.
Dependent on Admission Rx to be accurate
Dependent on the correct PCP in computer
Dependent on patient understanding med list
Health literacy
Large d/c packet—too much information
Teach back
Outpatient EMR and Inpatient EMR
Dependent on f/u phone call
Numbers not accurate
37.
Define the components of an accurate
medication reconciliation
Recognize gaps and inconsistencies in the
medication reconciliation process
Identify next steps in your practice to improve
medication reconciliation
40.
How-to-Guide: Prevent Adverse Drug Events by
Implementing Medication Reconciliation.
Cambridge, MA. Institute for Healthcare
Improvement; 2011 (www.ihi.org)
2013 Hospital National Patient Safety Goals
(www.jointcommission.org)
Van Sluisveld et al. BMC Health Services
Research 2012, 12:170
http://www.biomedcentral.com/14726963/12/170
41.
Greenwald, et al. Medication Reconciliation: A
Consensus Statement from the Stakeholders.
Journal of Hospital Medicine 2010 5(8) 477-485
Smith, M, et al. In Connecticut: Improving Patient
Medication Management in Primary Care. Health
Affairs 2011 30(4) 646-654
Mueller, S, et al. Hospital Based Medication
Reconciliation Practices: A Systematic Review
Arch Intern Med. 2012;172(14):1057-1069.
Notes de l'éditeur
2009 –review of omitted and discharged medications in discharge summary
Bottom line—many organizations have recognized the importance of medication reconciliation as part of quality medical care to prevent errors
Minimal application/need for Med Reconciliation
Make them aware of the importance of accurate medication list
Who ordered , what is the dose—what dose it look like, where did you get it, when did you last take it, why are you on it
Anticoagulants, insulin, theophylline, narcotics
There are many of studies that show that this can workProject Red