Lessons from the High 5s Project Margaret Duguid Former Pharmaceutical Advisor Helen Stark Senior...
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- Slide 1
- Lessons from the High 5s Project Margaret Duguid Former
Pharmaceutical Advisor Helen Stark Senior Project Officer 14
November 2014
- Slide 2
- Overview Background and goals Project methodology Lessons
learned Australian results National Safety and Quality Standard 4
Medication Safety
- Slide 3
- WHO High 5s Project Established by WHO in 2007 International
collaborative WHO, Joint Commission International and 9 countries
Australia, Canada, Germany, France, The Netherlands, Singapore,
Trinidad & Tobago, UK, USA Funded WHO, AHRQ, Commonwealth Fund
5 year project
- Slide 4
- WHO High 5s Project Aim Determine feasibility of implementing
Standard Operating Protocols (SOPs) in no. countries, healthcare
environments Assess impact on patient safety Slide 1 of 14
- Slide 5
- WHO High 5s Project Standard Operating Protocols (SOPs)
1.Correct procedure at correct body site 2.Medication accuracy at
transitions of care (medication reconciliation) 3.Concentrated
injectable medicines
- Slide 6
- www.ismp-canada.org/medrec/
- Slide 7
- Project oversight Internationally High 5s Steering Group Face
to face meetings 2 x year Monthly teleconferences High 5s website
E- bulletin for High 5s hospitals Webinars International hospital
meeting Nationally Medication Continuity Expert Advisory Group
- Slide 8
- Medication reconciliation SOP
- Slide 9
- Medication errors at transfer of care the problem Admission
Discharge Admission Histories 10 -67% contain errors 1 Up 1/3
errors PADE 2 Medication orders 30 70% patients had discrepancies
Between history and admission orders 3 Internal transfer 62%
patients had 1 unintentional discrepancy 36% PADE 4 Discharge
orders 41% patients had 1 discrepancy 23% omissions 5 Readmission
2.3 x more likely if 1 med omitted 6 1. Tam VC, Knowles SR et al,
CMAJ 2005 2. Cornish PL, Knowles SR, Archives Int Med 2005 3NICE
NPSA Tech Bulletin medication reconciliation 2007. 4. Lee J et al
Annals Pharmacotherapy 2010 5.Wong J et al Annals Pharmaco 2009
6.Stowasser, J Pharm Pract Res 2002 1
- Slide 10
- Medication reconciliation the solution Formalised medication
reconciliation at admission, transfer and discharge reduces
medication discrepancies (errors) by 50 94% 1-4 1.Vira T, Colquhoun
M,et al. Qual Saf Health Care 2006;15:122-6. 2.Pronovost P, Weast
B, et al. J Crit Care 2003;18:201-5. 3.Santell JP. Jt Comm J Qual
Patient Saf 2006;32:225-9. 4.Rozich JD, Resar RK. J Clin Outcomes
Manage 2001;8:27-34
- Slide 11
- Medication reconciliation Medication reconciliation is the
formal process in which health care professionals partner with
patients to ensure accurate and complete medication information
transfer at interfaces of care.
- Slide 12
- Medication reconciliation SOP Formal, structured process Staff
trained Multidisciplinary Doctors, nurses, pharmacists, pharmacy
technicians Partnership with patients, families, carers Integrated
into existing processes of care Within 24 hours of admission Phase
1 On admission for patients 65 years of age admitted through
emergency department to a hospital ward
- Slide 13
- Medication reconciliation process Step 1 Obtain a best possible
medication history (BPMH) Step 2 Confirm the accuracy of the
history Step 3 Reconcile the BPMH with prescribed medicines Step 4
Supply accurate medicines information
- Slide 14
- Interview patients and/or carers ( if possible) Systematic
approach Compile an accurate and comprehensive list Current
medicines patient taking prescription, OTC, complementary medicines
Recent changes, medicines ceased Step 1 Obtain a best possible
medication history (BPMH)
- Slide 15
- Verify with one or more sources Carer or family Medicine
containers (including blister packs) Medicines lists (patients) GP
lists, records Community pharmacy records Electronic/paper health
records, discharge records Medication charts from other facilities
e.g. nursing home Confirm accuracy of history Step 2
- Slide 16
- Document in one place in patient record Use to : Document BPMH
Document sources of information Reconcile history with prescribed
medicines. Document issues, discrepancies and actions. Keep with
NIMC for easy access One source of truth
- Slide 17
- Compare with medicines ordered Resolve discrepancies with
prescriber, document changes Step 3 Reconcile BPMH with prescribed
medicines
- Slide 18
- Slide 19
- The person taking over the patients care is supplied with an
accurate and complete (reconciled) list of the patients medicines
and explanation of any changes. Internal transfer of care (e.g ICU
transfers) Discharge Care provider Patient and carer Step 4 Supply
accurate medicines information
- Slide 20
- Project methodology 1.Complete AHRQ patient safety culture
survey 2.Implement Medication Reconciliation SOP Using QI
methodology 3.Evaluation plan Implementation experience survey (6
monthly) Performance measures Rate and quality of medication
reconciliation Analysis of SOP related adverse events In-depth
interviews with 3 sites 5 sites in Australia
- Slide 21
- 21 Project implementation in Australia Commenced January 2010 -
18 health services 2 x 2 day workshops 2010 2 x 1 day workshops in
2011 Video conference 2013 Teleconferences - monthly then 2nd
monthly Webinars, email newsletter All materials posted on High 5s
website Support from senior project officer
- Slide 22
- High 5s workshop 2011 Poster award winners High 5s hospitals
workshop Peoples choice
- Slide 23
- Implementation resources
- Slide 24
- Slide 25
- 25 Medication reconciliation resources... Medication management
plan + implementation resources MATCH UP Medicines Resources
www.safetyandquality.gov.au
- Slide 26
- Medication reconciliation resources Get it right. Taking a best
possible medication history 1. Video CD and You tube channel www.
Safteyandquality.gov.au 2.Online learning module
http://learn.nps.org.au/
- Slide 27
- 27 AUSTRALIA: Australian Commission on Safety and Quality in
Healthcare Improving quality and timeliness of information on
admission Bring medicines with patient Patients medicines lists
Engaging with consumers Mistakes can happen with your medicines How
to prevent them Have a medicines list
- Slide 28
- Implementation Strategy Oversight of implementation Project
work plan Risk assessment of proposed process Pilot testing Spread
methodology Communication plan Evaluation Strategy Maintenance and
improvement
- Slide 29
- Reasons for withdrawal 6 Australian health services withdrew
Change in priorities 2 Lack of resources for evaluation,
independent observer2 Lack of resources for MR process, evaluation1
Concern re MR taking focus away from medication review1 Lack of
perceived benefit1
- Slide 30
- Lessons (International) Full implementation was challenging
Reliant on pharmacists for success Additional pharmacists needed
for: More timely BPMH, medication reconciliation Coverage for after
hours, weekends and holidays Coverage of new areas, wards units
Performance measurement essential
- Slide 31
- Lessons Challenges and barriers Barriers and challenges to SOP
implementation Lack of resources - Training materials, medication
reconciliation form Lack of human resources for: Med Recon Data
collection Ongoing training Competing priorities Considered
Pharmacy Business Lack of buy in by: Organisational leadership
Senior staf f Lack of Technology to support Med Recon
- Slide 32
- Lessons Benefits of SOP Reported benefits of the SOP Positive
impact on: Related activities Patient care Reduced medication
discrepancies and potential ADEs Measurement data used for business
case to gain additional pharmacist resources Improved communication
between hospitals and community care providers Improved
multidisciplinary teamwork Improved documentaton
- Slide 33
- Drivers for SOP implementation National guidelines and
standards Accreditation requirements Access to community dispensing
data Pharmacy technicians
- Slide 34
- What makes for effective and sustainable medication
reconciliation? Recognition as a patient safety priority Senior
leadership support from the health service executive and senior
clinicians Interested and influential clinical champion(s)
Resources to conduct medication reconciliation and measure
improvement
- Slide 35
- Effective and sustainable medication reconciliation (contd)
Ongoing training of clinical staff Policies and procedures on
medication reconciliation Integration of Med Rec into existing work
flows, electronic health records and clinical information
systems.
- Slide 36
- Further information on High 5s project
http://www.who.int/patientsafety/implementation/solutions/high5s/High5_InterimReport.pdf?ua=1
- Slide 37
- NSQHS STANDARD 4 MEDICATION SAFETY
- Slide 38
- Medication Safety Standard
- Slide 39
- High 5s Project Resources
- Slide 40
- Medication safety standard
- Slide 41
- Slide 42
- Australian Project Results Margaret Duguid Pharmaceutical
Advisor Helen Stark Senior Project Officer
- Slide 43
- Importance of measurement Evaluation Strategy Evaluation
Results Resources
- Slide 44
- Tam VC, Knowles SR, Cornish PL et al. Frequency, type and
clinical importance of medication history errors at admission to
hospital: a systematic review. CMAJ, 2005; 173:510-515 The
Problem
- Slide 45
- Recent Australian paper 1 Multi-centre, prospective
observational study in 8 EDs Patients taking more than one medicine
and a GP referral letter (median 6) GP referral letters compared
with BPMH taken by ED pharmacist n=414 patients 1. Taylor S et al,
Australian Family Physician Vol. 43, No. 10 Oct 2014
- Slide 46
- The Problem 87.2% patients had one or more discrepancies
between BPMH and GP referral letter Median no. of discrepancies was
3 Most common: omission of regular medicine or inclusion of a
medicine patient no longer taking 62.1% of patients had one or more
discrepancies of moderate or high significance
- Slide 47
- Multi-component evaluation strategy Measurement an integral
component of the SOP 1.Performance measures 2.SOP implementation
experience 3.Event Analysis
- Slide 48
- 1. Performance Measures Four years of data (June 2010 to June
2014) Four measures (MR1 4) 10 hospitals contributing, staggered
implementation Project level results show significant variation
from hospital to hospital and country to country Present Australian
data only
- Slide 49
- MR1: Percent of patients reconciled within 24 hours of decision
to admit Purpose: Measure hospitals capacity to reach as many
eligible patients as possible Creation of BPMH, identification of
discrepancies & communication to prescriber within 24 hours
Method: Eligible patients: 65 years and over admitted through ED to
inpatient services All eligible patients or random sample of 50
using approved sampling method Monthly data collection Entry into
High 5s secure website, approved by Commission Goal: 100%
- Slide 50
- MR1: Percent of patients reconciled within 24 hours of decision
to admit MR1 ranged from 41.8% to 59.4% across participating
hospitals with an average of around 50.4% Trend line stable Key
finding: Reconciliation within 24 hours regarded as ideal for
patient safety but difficult to achieve for majority of
hospitals
- Slide 51
- MR1: Percent of patients reconciled within 24 hours of
admission
- Slide 52
- Quality measures: MR 2,3,4 Purpose: To verify quality of
medication reconciliation process Use independent observer to pick
up outstanding medication discrepancies Intentional vs
unintentional, documented vs undocumented Method: Chart audit
(n=30) from sample of 50 taken for MR1 Prospective or retrospective
Monthly then quarterly or six monthly if stable Data verification
& entry into High 5s website Goal: Aim to reduce to a minimum
MR3 target of less than 0.3 per patient MR4 no target
specified
- Slide 53
- Measure Description MR-2 Mean number of outstanding
undocumented intentional medication discrepancies per patient MR-3
Mean number of outstanding unintentional medication discrepancies
per patient MR-4 Percentage of patients with at least one
outstanding unintentional discrepancy Quality measures: MR 2,3,4
Measuring accuracy of the medication reconciliation process
Discrepancies that have slipped through the cracks MR2 example:
betablocker stopped by surgeon before surgery but not documented
anywhere MR3 example: omission, commission, wrong medication,
strength, dose or form
- Slide 54
- MR2 mean undocumented intentional discrepancies per patient
Prescriber made an intentional choice to add, change or discontinue
a medication but decision not clearly documented Creates confusion,
additional work and could lead to ADEs
- Slide 55
- MR3 mean outstanding unintentional discrepancies per patient
Where med rec is conducted, hospitals achieved target of less than
of 0.3 outstanding unintentional medication discrepancies per
patient, with trend towards zero over time for several
hospitals
- Slide 56
- MR4 percent of patients with at least one outstanding
unintentional discrepancy
- Slide 57
- Limitations of MR1 - 4 Small sample size for MR 2 4 Only review
med recs done within 24 hours Definitional issues what to include
as a discrepancy/MR2 vs MR3 Inter-rater reliability issues
Prospective vs retrospective data collection Herbal medicines
should be documented on BPMH however omission considered to be
intentional and discrepancy not counted eg., MO didnt order Ginseng
but not documented OTC medicines should be treated same as
prescription meds because prescriber needs to make decision about
continuation or non continuation eg aspirin
- Slide 58
- 2. Implementation Experience Surveys All hospitals completed
survey every 6 months Annual interviews conducted in 5 hospitals
Provided additional insight on hospitals experience
- Slide 59
- Reported benefits from SOP Reduction in medication
discrepancies and potential medication errors Standardisation of
med rec processes across the hospital Spreading from admission to
discharge and improved business processes at discharge Embedding
process into hospital work flow and routine data collections -
strong framework for hospitals to meet relevant criteria in the
Medication Safety Standard 4
- Slide 60
- Reported benefits from SOP Improved teamwork & recognition
of importance of med rec among non-pharmacist clinicians and senior
mgt Improved communication with community health care providers and
patients Opportunity to participate in international patient safety
project and associated benefits of sharing lessons learned
nationally and internationally Access to Commission training
materials and resources Using High 5s data to obtain additional
pharmacy staff for medication reconciliation after
hours/weekends
- Slide 61
- Reported benefits from SOP Multi-facetted High 5s evaluation
strategy provided hospitals with in-depth understanding of the
medication reconciliation service Performance measures useful for:
Tracking improvement, providing feedback to staff, mgt Identifying
gaps in practice, training requirements Developing business case
for resources MR 1 and MR3 - most useful Majority will continue to
evaluate med rec with some moving focus to discharge Med rec now
part of usual care
- Slide 62
- The High 5s project has engendered pharmacists and medical
staff with a greater understanding of the value of preventing
adverse consequences from medication discrepancies and clear
documentation of their intentions. Although we believed that we
already performed medication reconciliation to a high standard, the
audit process has allowed us to become more consistent across our
service (metropolitan hospital)
- Slide 63
- Challenges staff resources /staff resistance No. patients
receiving medication reconciliation is closely tied to available
clinical pharmacist resources Medical and nursing staff often
report not their job Some nursing staff feel they lack the
necessary pharmaceutical knowledge to perform this task Hospitals
report some improvement in teamwork over project Real change
requires education at under graduate level Not my job!
- Slide 64
- Challenges lack of staff No. of clinical pharmacists varies
markedly by hospital and sector Private hospitals - less clinical
pharmacists resulting in lower rates and reduced ability to spread
med rec across the organisation Education of large numbers of staff
required significant initial and ongoing commitment &
resourcing (under estimated upfront) Hospitals were required to
re-allocate clinical pharmacy staff from other tasks to conduct med
rec and/or for project evaluation and education
- Slide 65
- How many hours per week does the hospital provide a medication
reconciliation service?
- Slide 66
- Challenges lack of electronic systems Lack of integration of
med rec (paper) with eMM systems Some sites had a new eMM system in
ED introd. during project Medication reconciliation is conducted in
all inpatient areas. Improving timely rates of medication
reconciliation on all eligible patients within 24 hours will only
be possible when electronic documentation of medication
reconciliation is available and this tool can interact with current
medicine management systems. (large metropolitan teaching
hospital)
- Slide 67
- Future Plans Plans to implement electronic systems for
medication reconciliation
- Slide 68
- 3. Event Analysis (EAs) 3 rd evaluation component Hospitals
required to actively seek and investigate events that should have
been prevented by the SOP EA systematic analysis of the facts &
contributing factors leading to an patient safety incident (mini
RCA) Link to SOP implementation
- Slide 69
- Event Analysis (EAs) 17 EAs reported by 6 hospitals No serious
ADEs reported over the course of the project Most events due to a
failure to undertake med rec in timely fashion Major contrib.
factors were lack of teamwork, education & training and poor
communication Those that did EA learnt from analysis of actual ADEs
Case studies used for education of other clinicians Improved
processes Business case for more resources
- Slide 70
- EA Case Study A 73 year old Parkinsons patient was admitted for
investigation and rehabilitation after a fall The patient had his
Webster pack with him which had clear dose times and directions to
give Parkinsons medicines at 6am, 10am, 2pm, 6pm and 10pm however
the MO ordered medicines for the first four dose times only
omitting all the 10pm doses The omitted medicines included:
levodopa/carbidopa CR200/50mg, mirtazapine 30mg, pregabalin 25mg
and quetiapine 50mg There was no clinical pharmacist on the ward
because the usual pharmacist was on leave with no replacement
cover
- Slide 71
- EA Case Study The patient was not given doses of his usual 10pm
medications for the next two days It was recorded throughout the
patients notes that the patient was having multiple mobility
issues. The nurse recorded that this could have been part of his
usual symptoms or alternatively, a worsening of his Parkinsons
symptoms i.e. Parkinsons tremor gradually worsening throughout
shift
- Slide 72
- EA Case Study The treating MO asked a clinical pharmacist on a
different ward to see the patient on the third day because of
worsening mobility The pharmacist interviewed the patient but he
was a poor historian and was unable to give an accurate medication
history The pharmacist then spoke to the patients wife (carer) to
establish the correct medicines as well as using the Webster Pack
brought into the hospital as the 2 nd source for the BPMH After
seeing the patient and taking the BPMH the medication errors were
noted and the Doctor was asked to amend the medication orders The
doctor re-charted all of the omitted medicines. The patients
symptoms gradually abated and he recovered fully the next day
- Slide 73
- Learning from EA The process of taking a BPMH and admission
reconciliation was introduced to JMOs at orientation The hospital
used case study to educate JMOs on importance of using multiple
sources to confirm the medication history, including blister packs
Business case for additional clinical pharmacist Involving the
medical and nursing staff as well as the Quality Manager in the
event analysis process has resulted in new policies and actions to
prevent near misses. The teamwork involved in the project has
resulted in greater cooperation between clinicians which in turn
has led to less medication errors (eg omission errors).
(metropolitan hospital)
- Slide 74
- Commission Resources SOP & Implementation Guide MMP, user
guide and flash presentation MATCH Up medicines brochures &
posters BPMH Video and online learning module Consumer wallet
- Slide 75
- Conclusion Feasible to implement High 5s Medication
Reconciliation SOP in different countries and cultures Requires
some local and national adaptation Improves patient safety Complex
process Challenging to implement, requires careful planning
Measurement is critical to successful implementation Now lets hear
from the hospitals
- Slide 76
- Acknowledgements High 5s hospitals Alfred Health Vic Armadale
Health Service WA Epworth Healthcare Richmond Vic Greater Southern
AHS NSW Logan Hospital, Qld Mater Health Services Qld Noosa
Hospital Qld Medication Continuity Expert Advisory Group North West
Regional Hospital TAS Prince of Wales Hospital NSW Redland Hospital
NSW Rockingham Hospital WA Royal North Shore Hospital NSW The
Wesley Hospital Qld
- Slide 77
- Australian Commission on Safety and Quality in Health Care
www.safetyandquality.gov.au E:
medsafety@safetyandquality.gov.au