© Institute for Safe Medication Practices Canada 2009® Passing the Baton: Medication Reconciliation at Internal Transfer and Discharge Olavo Fernandes

© Institute for Safe Medication Practices Canada 2009®

Passing the Baton:Medication Reconciliation

at Internal Transfer and Discharge

Olavo Fernandes PharmD, FCSHP

ISMP Canada

Safer Healthcare Now! National Call

Sept 10, 2009LCD Version

© Institute for Safe Medication Practices Canada 2009® Slide 2

Objectives

At the end of this session, participants will be able to:

1. Outline the key elements and general principles of an interdisciplinary internal transfer and discharge practice process.

2. Highlight strategies for overcoming common challenges to successfully implement medication reconciliation at discharge and transfer.

Open Discussion Forum:

3. To provide participants with an open forum for sharing current challenges, successes, lessons learned and controversies with medication reconciliation implementation at transfer and discharge.


Moving On From Admission….

• Feedback from teams:

• many have started and moved toward sustaining admission med rec and are now earnestly focused on internal transfer and discharge

• Requests to represent and revisit key principles of effective reconciliation at internal transfer and discharge


Unintentional Discrepancy Rates • Admission*

• 5/10 patients (Cornish P, Arch Int Med 2005;165:424)

• Transfer*• 6/10 patients (Lee J, 2007; manuscript submission)

• Discharge*• 4/10 patients (Wong J. Ann Pharmacother 2008;42:1373-9)

*~Many of these discrepancies are clinically significant

J Harrison TGHJ Harrison TGH

Practical Practical

Overview of Overview of Medication Medication

Reconciliation in Reconciliation in Acute Care Acute Care

Summary of the Medication Reconciliation Summary of the Medication Reconciliation Process at AdmissionProcess at Admission

Summary of the Medication Reconciliation Summary of the Medication Reconciliation Process at Internal Transfer and DischargeProcess at Internal Transfer and Discharge


Medication Reconciliation Medication Reconciliation at Internal Transferat Internal Transfer

Internal transfer is an interface of care associated with a change in patient status where medications are assessed and medication orders should be reviewed and updated

Internal transfer may include:

• Change in responsible medical service

• Change in level of care (critical care unit to hospital ward)

• Post-operative transfer and/or

• Internal Transfer between units



The goal of internal transfer is to ensure all medications are appropriate for the patient’s new status of care.

The Best Possible Medication Transfer Plan (BPMTP) is the most appropriate and accurate list of medications the patient should be taking after the transfer.

Summary of the Medication Reconciliation Summary of the Medication Reconciliation Process at Internal Transfer and DischargeProcess at Internal Transfer and Discharge



Internal transfer medication reconciliation involves assessing and accounting for:

• the medications the patient is taking prior to admission (BPMH)

• the medications from the transferring unit (medication administration record (MAR)

• the new post-transfer medication orders (includes new, discontinued and changed medications upon internal transfer).


Subset - National SurveySubset - National Survey

What Is The Optimal Strategy For What Is The Optimal Strategy For Internal Transfer? Internal Transfer? Wong C et al. UHN/ ISMPWong C et al. UHN/ ISMP


National Transfer Medication National Transfer Medication Reconciliation Team DescriptionsReconciliation Team Descriptions

Wong C et al. UHN/ ISMPWong C et al. UHN/ ISMP


Key Elements of Interdisciplinary Practice Model for Medication Reconciliation at Internal Transfer

(from national survey and clinician interviews)

Wong C et al. UHN/ ISMPWong C et al. UHN/ ISMP 1. Best Possible Medication History on admission

2. Clear assignment of responsibilities

3. Clear expectation of timeframe

4. Standardized tool / process

5. Comprehensive communication to all team members

6. Auditing and sharing results with staff

7. Standardized interdisciplinary clinician training

8. Support from leadership/ stakeholders


National Snapshot Of Transfer National Snapshot Of Transfer Medication ReconciliationMedication Reconciliation



Transfer: Clinicians Primarily Transfer: Clinicians Primarily ResponsibleResponsible


Sample Process: computer generated

paper-based transfer

orders formcommunity

hospital

Used with permission from Markham Stouffville

Hospital

Medication Reconciliation at Medication Reconciliation at DischargeDischarge

Should result in clear and comprehensive information for the patient Should result in clear and comprehensive information for the patient and other care providersand other care providers

The The Best Possible Medication Discharge Plan (BPMDP)Best Possible Medication Discharge Plan (BPMDP) is the is the most appropriate and accurate list of medications the patient most appropriate and accurate list of medications the patient should be taking after discharge. Should account for: should be taking after discharge. Should account for:

1.1. New New medications started in hospitalmedications started in hospital

2.2. Discontinued Discontinued medications (from BPMH)medications (from BPMH)

3.3. AdjustedAdjusted medications (from BPMH)medications (from BPMH)

4.4. Unchanged medicationsUnchanged medications that are to be continued (from that are to be continued (from BPMH)BPMH)

5.5. Medications held in hospitalMedications held in hospital

6.6. Non-formulary/formulary adjustmentsNon-formulary/formulary adjustments made in hospital made in hospital

7.7. New medications started upon dischargeNew medications started upon discharge

8.8. Additional comments as appropriate - e.g. status of Additional comments as appropriate - e.g. status of herbal medications/ supplements or medications to be herbal medications/ supplements or medications to be taken at the patient’s discretiontaken at the patient’s discretion

FOR WHOM? : Discharge Reconciliation

Safer Health Care Now! GSK: Med Rec 2007

• Best Possible Medication Discharge Plan (BPMDP) should be communicated to :• Patient

• Community Physician / Primary Care Physician

• Community Pharmacist

• Other Community health care providers

• Alternative Care Facility or Service

• Clearly Communicate Medication Status: • New, Discontinued, Adjusted or Unchanged

• Suggested/ preferred reference point for community clinicians: changes since admission to hospital

Synchronization Challenge of Discharge Tools

Patient Care System

Dear Dr

Letter

EMITT Letter

Patient schedule

DischargePrescription

Patient Wallet card

J. Wong BScPhmJ. Wong BScPhm

Manual Manual ElectronicElectronic ElectronicElectronic

Wong J. [Abstract]Wong J. [Abstract] Pharmacotherapy Pharmacotherapy 2006 ;26: 106 2006 ;26: 106

Medications may be altered: new, adjusted, discontinued

Ward

Decision to discharge patient

BPMDP

Home

Synchronized Synchronized OutputsOutputs

Discharge Discharge ReconciliationReconciliation

Electronically Generated

Prescriptions

Medication Information

Transfer Letter

Patient Medication Grid

Patient Medication Wallet Card

22 33 44 55

Best Possible Medication

Discharge Plan

Physician Discharge

Summary

66

Vertical : Patient Medication GridVertical : Patient Medication Grid

Patient FriendlyDischarge Medication List

Used with permission from Markham Stouffville HospitalDOCTOR:

LOCATION:

PATIENT:

Medication Reconciliation at Dryden Regional Health Centre

Transfer & Discharge WOW what a journey!!

Lorie-Anne Blair

Director of Patient Safety & Clinical Education

DRHC

Dryden Regional Health Centre

Dryden is centrally located in the most western portion of North western Ontario, approximately 360 km from Thunder Bay and 320 km from Winnipeg

41 beds - 31 acute care and 10 chronic care Approximately 20,000 Emergency room visits per

year. Average about 100 births per year. 33% of all hospital patients are over 65 years of age

and 15% are children. We have three operating theatres. And a variety of outpatient departments.

Medication Reconciliation Senior Management at DRHC made Medication

Reconciliation a priority in February 2008. A committee was formed which included:

Senior VP Director of the In-patient unit Physician Nursing Supervisor Pharmacist RN RPN Director of Patient Safety CCAC 2 Community Pharmacists

Transfer & Discharge Medication Reconciliation

Admission Med Rec. implemented in January 2008

Transfer & Discharge implemented in January 2009

Form changed significantly due to feedback from staff over time and the desire to include all three processes on one sheet.

Transfer Medication Reconciliation – The process

The only internal point of transfer was from East Unit to OR and back.

The paper form was placed with an in hospital med list for review by the MRP post operatively.

Med Rec. was completed by the Recovery Room nurse and the patient was returned to the floor.

Discharge Medication Reconciliation – The other process

Upon discharge the Physician reviews the Med. Rec. form and in hospital medications and incorporates the home meds. into their discharge orders.

The Discharging Nurse reviews the BPMH and compares them to the discharge orders and rectifies any discrepancies.

Auditing the Processes

In Jan 2009, audit process was changed to reflect all three processes.

We had fully implemented Admission Med Rec. and no longer found the discrepancy rate valuable – now we needed to focus on completion rates.

I collect all Med Rec’s from Clinical Records and analyze data

Medication Reconciliation Completion Rates 2009

0

20

40

60

80

100

Month

%

% of Admission Med.Rec. Completed

% of Discharge Med.Rec. Completed

New audit process

started April '09

May 2009: Error occurred in

data collection - limited data

available

Med. Rec. Completion Rates by Discipline2009

0

20

40

60

80

100

120

Month

Perc

enta

ge c

ompl

eted

% of Adm. Med. Rec.Completed by Nursing

% of Adm. Med Rec.completed by MD

% of Discharge Med. Rec.completed by Nursing

% of Discharge Med. Rec.completed by MD

May 2009: Error occurred in data collection - limited data available

Physician Completion of Admission Med Rec.

0.00

20.00

40.00

60.00

80.00

100.00

120.00

Physicians

% C

om

ple

tio

n

No peaking!!

Extremely powerful data!!Physician Completion of Discharge Med. Rec.

0.0010.0020.0030.0040.0050.0060.0070.0080.00

Viher

joki

Maz

ursk

i

Lout

tit

Dahmer

Cortens

Whit

take

r

Dahmer

Porte

r

Gag

non

Kehler

Shahi

Fairle

yDove

Mut

rie

Rutka

Physician

% C

om

ple

te

The graph of shame!

% of Physician completion of Discharge Med. Rec.

Ahhhhhh!!! Transfer Med. Rec.

Transfer Medication Reconciliation Completion Rates

0

33.33333333

0

20

40

60

80

100

July Aug

2009

% C

ompl

eted % Total completion

% RN completion

% MD completion

One lonely signature!!

Successes

Admission Medication Reconciliation is standard procedure and Physicians are completing greater than 95% of Admission Medication Reconciliation’s.

Much better collaboration between Physician, Nurse and Pharmacist on Admission.

We have seen a 50% decrease in the number of medication incidents.

There have been other interventions implemented during this time to decrease Medication Errors – not all the decrease can be attributed to Med. Rec., but a significant portion can be.

#1 Incident report generator

Less than 50% of last years #’s

Challenges

Buy in from the MRP and visiting Specialists.

Buy in from the staff. Nurses forgetting where to sign. Form changes: should have used

small PDSA cycles rather than edits and trials with all staff – even though we were small

Plans

1:1 meetings with Nurses & Physicians to review process

No further changes to forms Development of a tracking method

for staff to identify good catches of unintentional discrepancies.


OPEN FORUM


Common Challenges and Strategies in Internal TransferCommon Challenges and Strategies in Internal Transfer


Common Challenges and Common Challenges and Strategies in DischargeStrategies in Discharge

Used with permission by : EHR and Medication Reconciliation US PanelUsed with permission by : EHR and Medication Reconciliation US Panel

Medication Reconciliation in the Community

ISMP Canada / O. Fernandes UHN ISMP Canada / O. Fernandes UHN

Framework: Ambulatory Medication Reconciliation ModelFramework: Ambulatory Medication Reconciliation Model Creating the most “up to date” medication record (BPMH)

(UHN/ SHN Home Care Pilot)

Patient and Family Interview

Medication Information from all

other sources

document

“up to date” medication

record (BPMH)

“medication discrepancies that

require clarification”

Compare:Compare:

Review and follow

up where indicated

Examples:

•Medication vial inspection

•Referral record

•Community pharmacy

•Hospital Discharge Summary


Documents

© Institute for Safe Medication Practices Canada 2009® Passing the Baton: Medication Reconciliation at Internal Transfer and Discharge Olavo Fernandes