One of the Institute of Medicine s 10 rules for health

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1 MEDICATION RECONCILIATION TOOL A Practical Tool to Reduce Medication Errors During Patient Transfer from an Intensive Care Unit Peter Pronovost, MD, PhD, Deborah Baugher Hobson, BSN, Karen Earsing, RN, MS, Elizabeth S. Lins, RN, BS, Michael L. Rinke, Katherine Emery, Sean M. Berenholtz, MD, MHS, Pamela A. Lipsett, MD, and Todd Dorman, MD Abstract Objective: To decrease medication errors that occur during the transfer of patients from a surgical intensive care unit (ICU) by institution of a computerized medication reconciliation tool. Design: Prospective cohort study. Setting and participants: Patients admitted to a 1-bed surgical ICU in an academic medical center. Measurement: Proportion of medical records with at least 1 error identified. Secondary outcomes included compliance with the tool and number of medication orders changed. Results: Over the 1-year study period, 1 medication reconciliation forms were completed. 3 medication orders were changed as a result of the medication form, and 99 (1%) individual patients required at least 1 change. An average of 1. orders were changed per week, affecting an average of patients per week. There was a high rate of compliance with the form. Conclusion: The implementation of a simple, inexpensive tool is associated with a decrease in medication errors that reach patients during transfer from a surgical ICU. One of the Institute of Medicine s 10 rules for health care system redesign included in its report Crossing the Quality Chasm specifies that patient safety must become a systems property as opposed to a personal responsibility [1,]. Other industries have achieved high levels of safety using a systems approach. For example, by designing systems that include independent redundancies, overlapping focus, and shields from error, the aviation industry reduced accessibility to preventable mistakes [3]. Few comparable systems presently exist in the health care environment []. Preventable adverse drug events (ADEs) are one of the more common medical errors and are often the result of system malfunctions and lack of independent redundancies. Preventable ADEs are associated with 1 in error-induced injuries or deaths, cost between $000 and $00 per event, increase length of stay by 1.7 to. days, and occur at an estimated annual rate of 1900 incidents per hospital [ 9]. Thus, these errors are an important area of focus for system improvement efforts. Patients are especially vulnerable to medication errors during handoff periods, such as at admission or transfer from one unit to another. This vulnerability is a result of poor communication between care teams [10,11]. In this article, we report on the outcomes of an intervention that was designed to prevent the occurrence of medication prescribing errors during the transfer of patients from a surgical intensive care unit (ICU). Methods Tool Development and Implementation In February 00 a quality improvement team implemented an electronic medication reconciliation tool on a 1-bed surgical ICU at Johns Hopkins Institution. The team consisted of an ICU physician, a nurse manager, and nursing leaders. Nurses used the tool to record all appropriate preoperative and current medications for patients upon admission to the ICU and to check transfer orders to confirm that all appropriate medications would be continued on the next unit. The electronic tool was based on a paper medication reconciliation form that had been implemented on 3 other ICUs and medicine floors in the institution. It consisted of an Excel spreadsheet containing instructions, data collection instruments, standardized graphs to evaluate outcomes, and a calculator to estimate cost savings from avoided medication errors (Figure 1). This electronic version was placed on the point-of-care computers in the ICU (Eclypsis), and the form was connected to the patient s electronic chart, keeping all (continued on page 9) From the Johns Hopkins Medical Institution and the Johns Hopkins School of Medicine, Baltimore, MD. JCOM January 00 Vol. 11, No. 1

2 REPORTS FROM THE FIELD PATIENT SAFETY (continued from page ) The Johns Hopkins Hospital Transfer/DC Medication Tool From: To: Transfer/Discharge Medication Tool Admission Data Allergies Unit: Allergies: PCN hives, ASA dizziness & upset stomach Unit Admit Time: Pre-Hospital Medication Medication: synthroid Dose: 0.1 mg Frequency: qd Status: Data Source: 1 Ordered in the ICU: drug unwarranted Ordered on Transfer: drug unwarranted Medication: nexium c1 Dose: 1 Frequency: qd Status: Data Source: 1 Ordered in the ICU: drug unwarranted Ordered on Transfer: drug unwarranted Medication: c Dose: Frequency: Status: Data Source: Ordered in the ICU: Ordered on Transfer: Discrepancy: Additional ICU Medications Medication: ranitidine Dose: 0 mg Frequency: qh Medication: gatifloxicin c3 Dose: 00 mg Frequency: once Ordered on transfer: drug unwarranted Medication: insulin c Dose: sliding scale Frequency: qh Ordered on transfer: DISCREPANCY, see below Discrepancy: yes, team changed orders Medication: Fentanyl PCA c Dose: 0/0//10 Frequency: PRN Medication: reglan c Dose: 0 mg IV Frequency: PRN Medication: narcan c Dose: 0. mg IV Frequency: PRN Medication: Dose: Frequency: Ordered on transfer: Discrepancy: Transfer Data Transfer Date: Reconciliations Have pre-hospital orders been reconciled to transfer orders? Yes Have ICU orders been reconciled to transfer orders? Yes Have all discrepancies been resolved prior to transfer? Yes Were transfer orders changed? Yes Comments: Are allergies correctly on transfer orders: Allergies listed correctly Was pt ordered any medication to which he/she is allergic? No Totals # of meds on Transfer Orders: 7 Total # of Changed Orders: 1 Figure 1. Medication reconciliation form. Vol. 11, No. 1 January 00 JCOM 9

3 MEDICATION RECONCILIATION TOOL information in a centralized location and avoiding an additional paper-based system. The point-of-care information system does not contain computerized physician order entry (CPOE) but does contain a list of medications. ICU nurses recorded all preoperative and ICU-ordered patient medications on the electronic form within hours of admission. New medications were added by the bedside nurse as ordered. Prior to transfer, the bedside nurse reviewed the form, paying close attention to discrepancies between ICU transfer orders and those listed on the medication reconciliation form. The nurse also used the medical record to confirm that allergies were listed correctly. If inconsistencies were noted, the bedside nurse notified the patient s physician to confirm that the change was appropriate. If the transfer orders were subsequently altered, the incident was considered a medication error. The initial completion of the form takes approximately 10 minutes and the reconciliation of medications on transfer takes approximately minutes. All nurses were trained in the use of the tool during a 1-minute individual training session provided by the nurse managers, a process now included in new staff orientation. The unit s performance improvement committee, consisting of nurse managers and educators, promoted the use of this tool. This was accomplished by encouraging staff to use the tool and by nurse managers soliciting staff concerns regarding barriers to using the tool. At monthly staff meetings, the performance improvement team presented staff with data regarding compliance with the medication reconciliation tool and encouraged them to improve performance when appropriate. Measures and Analysis Using the ICU s electronic medical record system (Eclypsis), the nursing performance improvement chair and the assistant nurse manager gathered data on patients admitted to the ICU between February 00 and February 003. The primary measure was the proportion of medical records with at least 1 error identified. This was defined as the number of patient charts in which at least 1 medication order had been changed divided by the total number of completed medication reconciliation forms that week. Secondary outcomes included compliance with the tool, total number of errors identified, and total number of medication orders changed. Compliance with the tool was defined as the number of completed medication reconciliation forms divided by the total number of transferred patients for a given week. Using published data, we also estimated the tool s impact on economic outcomes. We estimated that on average 1 ADE costs $1 and that % of potential ADEs (eg, medication errors) actually result in an ADE [7 9]. Therefore, each medication error or missed allergy identified represents an $7.0 savings ($1 0.0) from ADE prevention. This study was approved by the medical center s institutional review board. Results Over the assessment period, 1 medication reconciliation forms were completed, and 1,0 medication orders were reviewed. 3 (%) medication orders were changed as a result of the medication reconciliation form, with 99 (1%) individual patients requiring at least 1 change of their medication orders. On average, 1 medication orders were changed per week (Figure ), and patients needed at least 1 change per week (Figure 3). There were 37 allergy listings (%) among the medication order discrepancies changed over 1 year. There was a high rate of compliance with this intervention. After week, staff completed the medication reconciliation form on 9% of discharges and sustained a high rate of performance throughout the year (Figure ). We estimate that the ICU s annual savings from this medication reconciliation intervention was $,000 (3 errors 0.0 $1) [7]. Discussion We have implemented a simple, inexpensive tool that detected medication errors in transfer orders in a surgical ICU. Use of this tool, and the independent redundancies it provided, prevented potentially harmful mistakes from occurring in 1% of patients. The form was easy for nurses and physicians to use. The self-evident value of the form, feedback provided by nursing leaders, and ease of use helped to sustain a high compliance rate with this intervention. We believe the week-to-week variation in medication errors was due to systemic changes such as in the float pool of nursing staff, resident workload (both the number and severity of patients), and the rotations and experience of the house staff. Prior to this intervention, reconciliation of medication transfer orders was not a system process and was left solely to the discretion of physicians and sometimes nurses. Presumably, physicians continued to individually check transfer orders after the medication reconciliation tool was implemented, suggesting the ineffectiveness of this approach. If the tool had not been in place, most of the 3 incorrect medication orders would not have been detected. We believe that the medication reconciliation tool provided a new systemic defensive layer by including the nursing staff in the process of verifying medication transfer orders. Simple checks that create independent redundancies in patient care systems can provide opportunities for improving the quality of health care. A notable aspect of the medication reconciliation intervention was its self-perpetuating course. To date, the electronic tool has been implemented in ICUs and medicine floors via hospital and nursing staff without administrative involvement. In our experience, this is one of the unusual instances 30 JCOM January 00 Vol. 11, No. 1

4 REPORTS FROM THE FIELD PATIENT SAFETY Orders changed, n Week Figure. Number of medication orders changed Patients, n Week Figure 3. Number of patients requiring at least 1 medication change. Vol. 11, No. 1 January 00 JCOM 31

5 MEDICATION RECONCILIATION TOOL 100 Form completion rate, % Week Figure. Compliance with the medication reconciliation form. where an improvement effort spreads organically through a health care organization. We hypothesize that 3 main variables led to the spread and success of the intervention. First, the problem of medication errors is clear, consequential, and challenging. ADEs are easily recognized by all health care practitioners, and successful interventions offer prompt and tangible results. Furthermore, despite many attempts at improvement, the problem of ADEs persists. Second, the simple and concise nature of the computerized tool reduced staff objections and obstacles. The convenient boxed version of the tool we developed, with Excel spreadsheets and instructions, facilitated easy implementation and an efficient mechanism to provide feedback to staff. Nurse managers soliciting concerns regarding form use, addressing barriers, and keeping staff informed monthly about compliance empowered staff to become active participants in the medication reconciliation process. The third and perhaps most important reason for the intervention s success was nursing s ownership of the intervention. The nursing staff had a leadership role in the project and received due credit for the results in publications and meetings. Nurses play an essential role in patient care, and continued collaboration is crucial to improvements in quality and safety. Teamwork is critical in any workplace, particularly health care, where a culture of safety brings about improved patient outcomes [11]. While these results are significant, we recognize this study s limitations. First, our definition of a medication error, although practical, could be debated. By defining a medication error as a change in transfer orders, we identified only a subset of prescribing errors and may have missed other types of errors in prescribing, dispensing, and administering. Nonetheless, the mistakes identified in our intervention were common and represent a significant opportunity to improve care. Second, we did not monitor the prescribing mistakes that persisted after the 1-year assessment period. In another ICU at our hospital, we manually examined patient charts and confirmed that medication reconciliation eliminated medication errors as defined in this study; given the significant expense of this audit and our ability to eliminate mistakes, we elected not to replicate this process [1]. Third, our study was limited to a 1-bed surgical ICU and may not be broadly applicable. However, our hospital s original medication reconciliation project showed similar results and is being used in several other care areas at Johns Hopkins [13]. In addition, the VHA and Institute for Healthcare Improvement are advocating that similar systems be implemented to improve patient safety [1]. Finally, we conducted the study in an ICU that lacked a CPOE system. Nevertheless, caregivers will still need to reconcile medications with CPOE, especially if the CPOE system fails to communicate with the pharmacy information system. In our hospital, we have found a discrepancy between the patients orders and the pharmacy database in more than 30% of patients [1]. The need to ensure accurate communication of patient medications, as well as other information, during patient transfer is essential, regardless of whether CPOE is in use. The concept of medication reconciliation has broad application outside the ICU. Because of the inherent risk of errors during patient handoffs, this process also can be implemented at hospital discharge or during an outpatient visit. We are currently applying this concept to acute coronary syndrome patients at hospital discharge, ensuring that appropriate therapies are received, and to outpatients with multiple chronic diseases. In summary, use of this electronic medication reconciliation form was associated with a reduction in medication errors in transfer orders on a surgical ICU at an academic medical center. This tool is inexpensive, practical, and widely 3 JCOM January 00 Vol. 11, No. 1

6 REPORTS FROM THE FIELD PATIENT SAFETY accepted by physicians and nurses. The intervention also has wide applicability, including all inpatient hospital transfers, hospital discharges, and outpatient medicine. We look forward to additional studies of this process improvement. Corresponding author: Peter Pronovost, MD, PhD, Johns Hopkins Medical Institution, 901 South Bond St., Ste. 31, Baltimore, MD 131, References 1. Institute of Medicine. Crossing the quality chasm: a new health system for the 1st century. Washington (DC): National Academic Press; 001:7.. Sexton JB, Klinect JR. The link between safety attitudes and observed performance in flight operations. Proceedings of the Eleventh Symposium on Aviation Psychology; 001; Columbus, OH. 3. National Transportation Safety Board. We are all safer: NTSBinspired improvements in transportation safety. Available at Accessed 17 Dec Leape LL. Error in medicine. JAMA 199;7: Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;3:377.. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 199;7: Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997;77:301.. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Patient Study Group. JAMA 1997;77: Evans RS, Classen DC, Stevens LE, et al. Using a hospitalized information system to assess the effects of adverse drug events. Proc Annu Symp Comput Appl Med Care 1993: Zwarenstein M, Reeves S. Working together but apart: barriers and routes to nurse-physician collaboration. Jt Comm J Qual Improv 00;: 7, Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: Cross sectional surveys. BMJ 000;30: Pronovost P, West B, Schwartz M et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. JAMA. In press Pronovost P, Weast B, Schwarz M, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care. In press Unpublished data from the Johns Hopkins Center for Innovation in Quality Patient Care. Copyright 00 by Turner White Communications Inc., Wayne, PA. All rights reserved. Vol. 11, No. 1 January 00 JCOM 33