Performance Measures: Medication Reconciliation at Admission

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1 Background Transition points in the care continuum are particularly prone to risk, and the communication of medication information has been identified as a key area for improving the safety of health care delivery. 1, 2 In the Canadian Adverse Events Study, medication errors were identified as the second most common type of adverse event. 3 Medication errors have a substantial impact on client health outcomes and system resources, 4 and medication reconciliation is a cost-effective and beneficial model to prevent adverse drug events. 5 Medication reconciliation is widely recognized as an important safety initiative. In Canada, Safer Healthcare Now! identifies medication reconciliation as a safety priority. 6 The World Health Organization (WHO) has also developed a Standard Operating Protocol for medication reconciliation as an intervention designed to enhance patient safety. 7 Purpose of measuring medication reconciliation at admission Medication reconciliation is a structured process in which health care professionals partner with clients, families, and caregivers for accurate and complete transfer of medication information at transitions of care. Given the importance of medication reconciliation and the priority of establishing an accurate medication list at the beginning of services, medication reconciliation has been identified as an important indicator for medication safety. 8 Accreditation Canada requires organizations to measure the proportion of clients receiving formal medication reconciliation at admission, each visit, or the beginning of services, depending on the service area. The performance measure will provide a measurable guide for organizations as medication reconciliation is conducted more widely throughout the organization. 1 Institute for Healthcare Improvement. Medication Reconciliation Review. 2 Safer Healthcare Now. Medication Reconciliation Getting Started Kit. t.pdf 3 Baker, G., Norton, P., et al. (2004) The Canadian Adverse Events Study: The incidence of adverse events among hospitalized patients in Canada. CMAJ, 170: Medication errors, drug related problems and patient safety. The Translator. Volume 2, summer Canadian Pharmacists Association. 5 Karnon, et al. (2009) Model-based cost-effectiveness analysis of interventions aimed at preventing mediation error at hospital admission. J Eval Clin Pract. 15: Safer Healthcare Now! Getting Started Kit: Medication Reconciliation Prevention of Adverse Drug Events. 7 World Health Organization. High 5s - Action on Patient Safety Getting Started Kit. Assuring Medication Accuracy at Transitions of Care: Medication Reconciliation. 8 Nigam et al (2008). Development of Canadian safety indicators for medication use. Healthcare Quarterly, 11: Page 1 of 5

2 Sampling Strategies Teams in each service area should collect data for a sample of 20 charts per month. If the number of admissions to the service area is less than 20, teams should collect data for all admissions. Larger service areas may choose to review more charts each month depending on patient volumes. Charts reviewed should be taken from a random sample. Two strategies that could be used for selecting a random sample are described at the end of the protocol. Exceptions: Long Term Care Services: Due to the manageable number of admissions to Long Term Care settings, and the increased risk level of this client population, data should be collected for all admissions. Home Care Services, Case Management Services: Sampling for Home Care is based on discharged client charts. For clients with medication management as a component of care, teams should collect data for a sample of 10 discharged client charts per month. If the number of discharged clients for the month is less than 10, collect data for all discharged clients. Target Populations If organizations are not able to conduct medication reconciliation for all clients, they are permitted to select target populations of clients for formal medication reconciliation at admission. Defined target populations are shown on Accreditation Canada s organizational portal, and are based on evidence, e.g. risk, volume. Target populations of clients may not be applied to the denominator. This will permit valid comparisons and trending over time for performance measure data. Definitions Best Possible Medication History (BPMH): A comprehensive list of all medications a client has been taking prior to admission/visit/beginning of service. The BPMH is compiled using a number of different sources, and includes information about prescription medications, non-prescription medications, vitamins, and supplements, along with detailed documentation of drug name, dose, frequency, and route of administration. Page 2 of 5

3 For teams using standards: Medicine Services, Surgical Care Services, Long Term Care Services, Cancer Care and Oncology Services, Critical Care Services, Obstetrics/Perinatal Care Services, Acquired Brain Injury Services, Mental Health Services, Rehabilitation Services, Substance Abuse and Problem Gambling Services, Hospice Palliative and End of Life Services. Numerator: Number of clients admitted for the measurement period and receiving formal medication reconciliation. Include as an event for admission the process of accepting clients for medical and nursing care in a hospital or other health care institution for the diagnosis and treatment of disease and the maintenance of health. 9 Include as an event for medication reconciliation if steps are taken to achieve the following: 1. generate a comprehensive list of all medications the client has been taking prior to admission (Best Possible Medication History) 2. use the BPMH to create admission medication orders (proactive model) or make a timely comparison of the BPMH with admission medication orders (retroactive model) 3. discrepancies are identified, discussed, and resolved with the prescriber; and appropriate modifications to medications are made where necessary Denominator: Total number of clients admitted for the measurement period. For teams using standards: Emergency Department Services Formal medication reconciliation is implemented for clients with a decision to admit. Numerator: Number of clients in the Emergency Department with a decision to admit receiving formal medication reconciliation for the measurement period. 1. generate a comprehensive list of all medications the client has been taking prior to arrival at the Emergency Department (Best Possible Medication History) 2. use the BPMH to create admission medication orders (proactive model) or make a timely comparison of the BPMH with admission medication orders (retroactive model) 3. discrepancies are identified, discussed, and resolved with the prescriber; and appropriate modifications to medications are made where necessary Denominator: Total number of clients in the Emergency Department with a decision to admit for the measurement period. 9 MeSH : U.S. National Library of Medicine vocabulary for indexing articles for MEDLINE/PubMed. Page 3 of 5

4 For teams using standards: Home Care Services, Case Management Services Formal medication reconciliation is implemented at the beginning of service when medication management is a component of care. Numerator: Number of clients who begin receiving services including medication management as a component of care for the measurement period, having a BPMH completed, with discrepancies communicated to the appropriate health care practitioner. Include as an event for the beginning of service the process of accepting clients in order to provide health services for the diagnosis or treatment of disease or the maintenance of health. 1. generate a comprehensive list of all medications the client is taking at the beginning of service when medication management is a component of care (Best Possible Medication History) 2. conduct a timely comparison of the BPMH with medications being prescribed, dispensed, or administered during service 3. communicate the BPMH and discrepancies requiring resolution to the appropriate health care provider, and document actions taken in the client record Denominator: Total number clients who begin receiving services including medication management as a component of care for the measurement period. For teams using standards: Ambulatory Care Services Formal medication reconciliation is implemented for clients at each visit if medications have been discontinued, altered, or prescribed. Numerator: Number of clients receiving services for the measurement period and receiving formal medication reconciliation. 1. generate or update a comprehensive list of all medications the client has been taking prior to the visit (Best Possible Medication History) 2. conduct a timely comparison of the Best Possible Medication History with medications being discontinued, altered, or prescribed during the visit 3. discrepancies are identified, discussed, and resolved; appropriate modifications are made to the new medications list; and clients are provided with clear information about the changes Denominator: Total number of clients who had a visit where medications were discontinued, altered, or prescribed for the measurement period. Page 4 of 5

5 Methods to Generate a Random Sample: 1. Nth Client Method: Based on admission histories, teams will estimate the average number of clients for a month. Then, based on this number, calculate the nth number of clients to sample to ensure a random sample of at least 20 clients is achieved. For example, service area A has an average of 200 clients per month. The independent observer will select every 10 th client to achieve a sample of at least 20. Notes for Method 1: For the Nth client method, it is important to start at a random starting point, i.e. not always with the 3 rd or 4 th client. If one is sampling every 10 th client, the first client sampled should be a random digit selected between 1 and 10, and then every 10 th client thereafter. 2. X Days in a Month Method: Based on admission histories, teams will estimate the average number of clients for a month. Then, based on this number, calculate the mean number of clients per day, followed by the number of days required for the independent observer to ensure a random sample of at least 20 clients. For example service area B has an average of 200 clients per month resulting in an average of 6 clients per day. With this method three to four days could be randomly selected (random number generator) out of the month to conduct measurements. Notes for Method 2 Less preferable method due to several types of potential bias, such as selected days (i.e. 3 Mondays vs 3 Thursdays) having different performance. For the X days per month method, once the number of days to be sampled per month is determined, these days need to be randomly sampled within the month. Additional Notes for Selecting a Random Sample: Once an organization has selected one of the sampling strategies, this approach must be used consistently throughout the data collection period. To reduce potential bias, the independent observer should be the only one to know which sampling strategy is selected, and which cases will be reviewed. Page 5 of 5