Medication Reconciliation Process; Reducing Prescribing Errors Amjed Abu Alburak, RN, BSN, ACCPC CRN, Nursing Administration Medication Safety Program KAMC- CR, Kingdom of Saudi Arabia abualburaka@ngha.med.sa Saudi Heart Association January 29 th 2012
Acknowledgments Dr. Mubashar Kharal, Chairman, MSP/Consultant, Internal Medicine Ms. Janice Munday, Director, Clinical Nursing Ms. Souzan Al Owais, QM Specialist Mr. Saeed Al Dosari, Assistant Director, Pharmacy Dr. Hind Al Modaimegh, Clinical Pharmacist Ms. Hadeel Al Deraihem, QM Specialist RpH. Saad Al Nofaie, Team Leader, CIMS Ms. Julie Elizabeth Craig, CRN, Emergency Care Center Ms. Mona Al Mehaid, Manager, CIMS Mr. Abelardo Pineda, Senior Programmer Analyst Ms. Maha Al Mazyad, Application Analyst, CIMS Ms. Evangeline Jose, MSP Auditor Ms. Marilyn Tancio, MSP Auditor Mr. Norme Sandayan, MSP Secretary
Learning Objectives Medication Reconciliation - Definition - Process - Rational - Case where it can help Methods Results Tips for Success Take home Message
JCAHO s Definition of Medication Reconciliation Reconciliation is the process of comparing what the patient is taking at the time of admission or entry to a new setting with what the organization is providing to avoid errors of Transcription Omission Duplication of therapy Drug-drug Drug-disease interactions, etc. JCAHO. 2005 National Patient Safety Goals FAQs ; Available at: http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_f aqs.faqs; 4
The Reconciliation Process The basic steps: Collect an accurate medication history and home medication list (name, dose, route, frequency) Clarify inconsistent or questionable information Compare list to H&P, admission profile, medication orders on admission, transfer, & discharge including outpatient treatment Cite rational for medication changes or omissions Correct discrepancies, problems, or unclear changes within a reasonable time frame Communicate updated medication list to the providers of outpatient care 5
Rationale for Reconciliation Hospitals medical errors occur at care Interfaces: - 46% occur at admission or discharge - 27.5% omission error rate on hospital admission - 31.2% duplication error rate on hospital discharge Poor communication among caregivers (and patients) Fragmented continuum of care Illegible hand writing Rozich et al. JCOM 2001;8(10)27-34. Pronovost et al. J Crit Care 2003;18(4):201-5. Branowicki P. Coalition for the Prevention of Medication Errors Conference, 2002. Billman G. AAP Patient Safety Summit, 2002.
A. Cumadin 8 mg Po daily B. Avandia 8 mg Po daily C. Immodium 8 mg Po daily
A. Zestril 20 mg Po Q 6 hrs B. Inderal 20 mg Po Q 6 hrs C. Isordil 20 mg Po Q 6 hrs D. Plendil 20 mg Po Q 6 hrs
Where Medication Reconciliation Can Help? Admission Patient was admitted to a hospital for Community Acquired Pneumonia (CAP). Patient s medical history was significant for Atrial fibrillation. Chronic Warfarin therapy was not continued on admission because the patient's home dose was unknown. Patient s history was not clarified and NO Warfarin (nor any other anticoagulants) were initiated. On day 10, the patient developed an ischemic stroke. Patient never regained consciousness and subsequently died on day 32 due to respiratory complications. The case was resolved through settlement for $500,000. 10
Good Medication Histories AVOID Problems by evaluating: Allergies Vitamins & herbal products Over the counter products Interaction possibilities Drugs currently (or previously) prescribed Patient co-morbidity disease conditions 11
Old Process at KAMC Admission NURSE Obtain History PHYSICIAN Obtain History Document on Admission Assessment Database Process Orders Document on Admission Note/Form v Write Orders 12
Insanity is doing the same things the same way and expecting different results --Albert Einstein
Why Do We Need a Formal Medication Reconciliation Process at KAMC? Methods 77 Chart review data: Audits (3 units) show unacceptable rates of un-reconciled medications Admission 41% - 56% Ward A Ward B Ward C Total number of charts reviewed 27 29 21 Total number of medications reviewed 62 87 154 Total number of medication omitted* 35 36 82 % of un-reconciled medications 56% 41% 53% * Omitted Medications means it is been neglected/ignored or not prescribed
Use small rapid cycles of change PDSA Methodology Pilot in single area 15
Methods Developing Pre Printed Physician Medication Admission Order Form (All patient's active medications). Developing guidelines to outline procedures and responsibilities. Providing educational sessions & materials to accompany the new process.
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Post-Implementation of Admission Medication Reconciliation Results 19
% of Un-Reconciled Medication Pre - Implementation of Medication 60% Reconciliation 50% 40% 30% 20% A B C WARD 6 WARD 8 WARD 20 10% 0% 0 2 4 6 8 10 Audit Timing (Weeks) P value < 0.0001 Percentage of un-reconciled medication pre and post implementation of preprinted physician medication admission order form.
% of Unreconciled Medications on ADMISSION Pre & Post Printed Physician Medication Admission Orders ( Over - All HOSPITAL ) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 4th Quarter 2008 2011-MARCH-Week4 2011-APRIL- Week1 Pre-implementation of Medication Reconciliation Week2 Week3 Week4 2011-MAY- Week1 Week2 Week3 Week4 Week5 2011-JUNE- Week1 Week2 Week3 Week4 2011-JULY- Week1 Week2 Week3 Week4 2011-AUGUST- Week1 % medications unreconciled 75% reduction Week2 Week3 Week4 2011-SEPTEMBER- Week1 Week2 Week3 Week4 2011-OCTOBER- Week1 Week2 Week3 Week4 2011-NOVEMBER- Week1 Week2 Week3 Week4 2011-DECEMBER- Week1 Week2 Week3 Week4
The PATIENT is the overall key to success Involve family or caregiver Multidisciplinary team with champions (MD, RN, RPH) Encourage patients to bring their medications to each visit (SMS messages)
Start Small; one (1) patient, one (1) nurse and one (1) physician. * Do not rush to implement the change Spread process Admission Discharge Transfers Automation & Computerization. Education, Education, Education!! 23
Why Patient Education is important?
Safe Patient Care Is Our Goal 25