Medication Reconciliation

Leslie Ochs PharmD, PhD, MSPHAssistant ProfessorUNE College of PharmacyApril 27, 2014

Objectives

Describe the importance of medication reconciliation for patient safety

Identify opportunities, barriers and challenges in performing successful medication reconciliation

Identify strategies for effective medication reconciliation

Describe the importance of your role in effective medication reconciliation

Test Your Knowledge

1. What is the purpose of medication reconciliation?a. To ensure sure patient’s medications meet

current treatment guidelinesb. To decrease patient medication costsc. To reduce medication errorsd. To decrease the number of medications a

patient is currently taking

What is Medication Reconciliation?

“The process of comparing a patient's medication orders to all of the medications that the patient has

been taking. This reconciliation is done to avoid medication errors such as omissions, duplications,

dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are

rewritten. Transitions in care include changes in setting, service, practitioner or level of care”

Best suited for inpatient services

TJC - Issue 35, January 25, 2006

What is Medication Reconciliation?

“Reconciliation is a process of identifying the most accurate list of all medications a patient is taking – including name, dosage, frequency and route – and using this list to provide correct medications for patients anywhere within the health care system.”

Institute for Healthcare Improvement – 2007http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx

Best suited for outpatient services

What is Medication Reconciliation?

Process of reconciling a patient’s medication list at transitions of care

Ensures patient’s medications accurate on admission to a hospital or nursing home, at inpatient transfers, on D/C and in community or outpatient setting

Helps to reduce errors Omissions, duplications, incorrect doses and

DDI Improves communication

TJC - Issue 35, January 25, 2006

Mandates for Medication Reconciliation

2009 - National Patient Safety Goal 8

“Reconcile medications across the continuum of care” Ambulatory care Emergency and urgent

care Home care Inpatient services Long‐term care

100,000 Lives Campaign

Designed to improve care and avoid mortality

Medication reconciliation – key component

Joint Commission on Accreditation of Health Care Organizations

Institute for Healthcare Improvement

Pharmacist’s Letter 2010; Course No. 303

Importance of Medication Reconciliation

Difficulties in process No clear roles or responsibilities▪ Duplicate in patient’s medical charts▪ Documentation in different places▪ May or may not be in agreement

Difference in collecting information▪ Consider OTC “to be medications”?

Patient’s medical condition

Test Your Knowledge

2. What percentage of patients have unintended discrepancies on admission to healthcare facilities?a. 30%b. 25%c. 67%d. 59%

Why is it necessary to do medication reconciliation?

Adverse Drug Events (ADEs) happen frequently 5‐40% of hospitalized patients 12‐17% of patients after discharge

Transitions increase discrepancies and the risk for ADEs 70% of patients on admission have discrepancies 1/3 of these are potentially harmful ADEs

Unintended discrepancies 67% on admission 11‐59% harmful

Mueller et al. Arch Intern Med 2012;172:1057 Kwan et al. Ann Intern Med 2013;158:397

Types of Transitions

How does medication information flow in these transitions?

Electronic information Written information Patient reporting Team discussion Nursing handoff

Issues in Communication

Community Pharmacy Information• Use more than one pharmacy – not

complete• Poor communication between pharmacies• Insurance for some medication, cash for

others• Get medical information from patient or

familyLong Term Care• MD and pharmacist not on site• Assisted living may nit have medication review by

pharmacist

Discharge Instructions• Poor instructions between settings• Community Pharmacist is out of the

loop

Between MD• Direct Interaction – Hospital MD & PC MD – 3-20%• D/C summary at follow-up appt

• 1st – 12-34%• 4 week – 51-77%• Impact in care in 25%

Snow et al. J Hosp Med 2009;4:364 Hume et al. Pharmacotherapy 2012;32:e326

Care Coordination at Discharge Pharmacist not involved in home

services Limit information sharing with home

care b/misinterpret HIPPA Discharge visits may be overwhelming Often not one entity that takes

responsibility for coordinating care. Improved with: Patient-centered medical home Accountable care organizations

Hume et al. Pharmacotherapy 2012;32:e328

Patients at Risk for Transition Problems

Older Cognitive impairment End of life Low health literacy More than 5 medications/day Disabilities Low income Homeless New admission to long-term care

Hume et al. Pharmacotherapy 2012;32:e328

Is there evidence that medication reconciliation programs work?

Evidence to support pharmacist’s involvement 36% of patients had medication errors on

admission – 85% originated from medication list Strategies to reduce medication errors at

transitions include pharmacist medication review at D/C

Medication review and consultation in various settings▪ Reductions in MD visits, ED visits, hospital days and

costSchnipper et al. Arch Intern Med 2006;166:565Doyle E. September 2009

Hospital-Based Medication Reconciliation – Systematic Review

26 studies Provider

15 Pharmacist 6 Information technology 5 Other providers

Comparison Usual care

Discrepancies Intentional &

UnintentionalFeature Studies Showing

Reduction/Improvement

Medication discrepancies 17 of 17

Potential adverse drug events 5 of 6

Adverse drug events 2 of 2

Post discharge health care utilization

2 of 8

Mueller et al. Arch Intern Med 2012;172:1057

Unintentional Discrepancies Study #1

178 pts in Boston teaching hospital

Intervention ‐ Med rec, counseling with RPh, F/U telephone within 5 days

Control - RN discharge counseling, RPH reviewed meds without formal med rec

Results

▪ 1% Intervention group had pADE

▪ 11% Control group had pADE(p=0.01)

▪ Total ADEs - No difference

Study #2 14 teams; 2 teaching hospitals in

Boston 320 pts Intervention – Web based electronic

med application – “Preadmission Medication List (PML) Builder” used to facilitate med rec process

Control – Resident took med history, RPH check order, MD wrote D/C orders, RN educated on meds

Results

2 Randomized Controlled Studies

Schnipper et al. Arch Intern Med 2006;166:565

Intervention

Control

pADEs 170 230

Admission 44 49

Discharge 126 181

Relative Reduction = 0.72Schnipper et al. Arch Intern Med 2009;169:771

Test Your Knowledge

3. Which of he following are examples of the most common medication errors discovered by reconciling medications?a. Wrong doseb. Wrong patientc. Omission of medicationsd. Extra dose

Medication Reconciliation as a Patient Safety Strategy

Most common errors Improper dose or quantity Omissions Prescribing errors

Less common errors Wrong dose Extra dose Wrong patient Mislabeling Wrong administration technique Wrong dosage form

TJC - Issue 35, January 25, 2006

Medication Reconciliation as a Patient Safety Strategy

Continuation of a medication when patient no longer needs

Omission of outpatient medications on admission into the hospital

Fail to restart a medication at D/C when medication was temporarily discontinued during hospital stay

Medication Reconciliation Process

Verification Collection of the medication history

Clarification Ensure that medications and doses are

appropriate Reconciliation

Documentation of changes in the orders

Institute for Healthcare Improvement – 2007http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx

Prior to Medication Reconciliation

Starts prior to the visit Review list for duplicate therapies

Beta-blockers, HTN medications Remove discontinued therapies

Old antibiotic prescriptions Remind patient to bring in medications or

their list Prescription bottles best/medication list

Obtain list of medications actually filled from the pharmacy or Health Info Net

Medication Reconciliation Process at Every Visit

Ask all patients to provide a current list of medications, including OTC and herbals

Review medication with patient Reconcile and document patient’s medication

list and EMR medication list Check new medications for interactions/conflicts

with updated EMR medication list Provide patient with a paper copy of an

updated, reconciled medication list Identify who is responsible to resolve

discrepancies and duplications

What Medication Information Should be Collected?

Medications on the “home medication list” Prescription medications Sample medications Vitamins Nutraceuticals Over-the-counter (OTC) drugs Respiratory therapy-related medications

What information should the medication list Include? Drug name Dose Route Strength Frequency

Indication Last dose Who is providing

the information Who is collecting

the information

Sources for Medication

Prescriptions Over the counter medications and

supplements Family members and friends Samples Internet prescriptions Prescription assistance programs

Test Your Knowledge

4. Which of the following are TRUE in regards to information that should be collected about a patient’s medications? a. Only include prescription and OTC products on the

medication listb. Only include those medications that the patient takes

orallyc. Herbal and nutritional supplement information is

unimportant because these products do not interact with other medications

d. The most comprehensive and accurate list is important for medication reconciliation (Rx, OTC, Vitamins, Vaccines, etc.)

Medication History – Critical to Have a Complete List

Herbals Nutritional and dietary supplements Vitamins OTC medications Prescription medications Respiratory therapy medications

Inhalers and nebulization treatments IV solutions and medications Vaccines Radioactive medications Diagnostic and contrast agentsPharmacist’s Letter 2010; Course No. 303

Following Medication Reconciliation Process

Determine who should be aware of the changes to the medication list

Ensure sharing discontinued medications

Failure to communicate with pharmacies leaves prescriptions active on patient profiles that can be filled by patientsDon’t forget to share the updated medication list

What if you don’t have enough time for medication reconciliation?

Multiple chronic disease (>3) Multiple medications (>10) High risk medications

Heart medications Opioids Immunosuppressants Blood sugar medications

Medications with Narrow Therapeutic Index Anticoagulants Psychiatric medications Seizure medications

Barriers to Medication Reconciliation

No standardized process Difficult to obtain accurate

medication history Multiple providers involved in

patient’s care MD office is is not aware of

patient’s prescriptions

ASHP-APHA Medication Management in Care Transitions Best Practices 2013

Challenges to Medication Reconciliation

Understand the importance Obtaining complete and accurate

information Engage everyone in the process

Health care providers, patients and caregivers Create an expectation of the patient that

they receive a current medication list Develop patient responsibility to carry the

list Time to reconcile medications

Resources need to complete reconciled listASHP-APHA Medication Management in Care Transitions Best Practices 2013

Strategies for Medication Reconciliation

Review the workflow process and see how medication reconciliation can best be incorporated within the facility

Clearly define responsibilities Remind patients to bring medication bottles List printed at check-in, patient to review

while waiting for their appointment Quality audits and feedback on

performance/program

What features do successful medication reconciliation programs share?

Multidisciplinary Team Transitions involve many people - must involve a variety of providers Providers must communicate and collaborate well ‐ avoid turf issues and

silo approach Institutional Support CQI central to process - helps document positive outcomes Dynamic Pharmacy Team

Changing Roles▪ Reassessment of job responsibility▪ Support for pharmacist in expanded role

Pharmacy extenders can be very useful - pharmacy interns, residents, technicians

Training for pharmacy team▪ Reconciliation, prior authorization, documentation, communication, and

data management▪ Competencies & protocols to ensure high standards▪ Schools have focused on this in APPEs

ASHP-APHA Medication Management in Care Transitions Best Practices 2013Mueller et al. Arch Intern Med 2012:1067

What features do successful medication reconciliation programs share?

Metrics to show Return on Investment (ROI)

Types of metrics Readmit ED visits Med Rec problems Disease specific metrics Patient satisfaction Always plan goals and

data collection before program

Efficient transfer of information

Approaches for transferring information: EMR Prior authorization E-prescribing Contacting

provider/prescriber Billing options

Data to Justify Program

Share Information Well

ASHP-APHA Medication Management in Care Transitions Best Practices 2013

What does a “best practice” medication reconciliation program look like?

Best possible medication history (BPMH) Structured interview to identify all prescribed and

OTC medications AND Verify the results with at least 1 other reliable

source ofinformation▪ Medication vials▪ Patient medication lists▪ Community pharmacy record▪ Clinic record

Medication reconciliation BPMH AND Correct discrepancies

Kwan et al. Ann Intern Med 2013;158:397

What steps should be followed in creating a medication reconciliation program?

Make a standard form or guide to help carry out the process

Make sure the approach facilitates getting a complete list of

medications/treatments Dose, route, frequency, immunizations, allergies, herbals, etc

Put med list where it is easy to find Determine a timeframe for completion Assign responsible person at all transitions (e.g., admit,

discharge) Give patient a discharge med list Suggest patient carry discharge list and update Start with a small sample to pilot the process Provide education to all health care providers participating

in medication reconciliation Give feedback on program to providers

Pharmacist’s Letter 2010; Course No. 303

Community Pharmacist Role

Important component of medication reconciliation Communication with pharmacy to obtain accurate

medication history on admission▪ Important to reducing medication errors

Communication with patients after discharge▪ Counsel medications▪ Remind to stop taking unnecessary pre-admission

regimens▪ Answer questions▪ Medication record▪ Update information

Pharmacist’s Letter 2010; Course No. 303

Community Pharmacist Role Educate patients and family members to

serve as advocates Patients understand the complexities of the

medication process and the role they play in medication management

Allows patients to keep better track of medications they are taking

Have patients bring their medications to every healthcare encounter

Educate and empower patients to be responsible for their medication list

Pharmacist’s Letter 2010; Course No. 303

Medication Reconciliation Resources

The Institute for Healthcare Improvement (www.ihi.org) Case studies, literature review, resources, frequently

asked questions The Massachusetts Coalition for the Prevention of Medical

Errors (www.macoalition.org ) Safe practices, sample processes, toolkit, reference list

The Joint Commission (www.jointcommission.org ) Information on compliance with standards, frequently

asked questions, flow chart The American Society of Health‐System Pharmacists (

www.ashp.org) “how to guide, reference list, “clearing house information”

The Agency for Healthcare Research and Quality (www.ahrq.gov) Toolkit

Medication Form Example

Questions?

Post Question 1

1. All of the following are outcomes of an effective medication reconciliation process except:a. Promote overall continuity of patient careb. Increase in medication errorsc. Support safe medication use by patientsd. Encourage providers and health systems to

collaborate

Post Question 2

2. The important steps of an effective medication reconciliation as suggested by the Institute of Healthcare Improvement (IHI) include:a. Verificationb. Clarificationc. Reconciliationd. All of the above

Post Question 3

3. What information should a community pharmacist share when contacted by other healthcare providers to help update a patient’s medication list?a. Drug name, dose, route and strengthb. Medication frequencyc. Last refill or date receivedd. Healthcare provider who is collecting

medication informatione. All of the above

References

1. http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx2. Joint Commission on Accreditation of Health Care Organizations Sentinel Event Alert. Using

medication reconciliation to prevent errors. Issue, January 25, 2006. www.jointcommisson.org/sentinel_event_alert_issue_35_using_medication_reconciliation (Accessed April 15, 2014).

3. Improving Patient Safety: medication reconciliation basics. Pharmacist’s Letter 2010; Course No. 303

4. Mueller SK, Sponster KC, Kripalani et al. Hospital-based medication reconciliation practices: systematic review. Arch Intern Med 2012;172:1057

5. Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397

6. Snow V, Beck D, Budnitz et al. Transitions of Care Consensus policy statement. J Hosp Med 2009;4:364

7. Hume AL, Kirwin JL, Bieber HL et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy 2012;32:e326

8. Doyle E. Medication reconciliation done right. September 2009. www.todayshospitalist.com/index.php?b=articles_read&cnt=871 (Accessed April 15, 2014).

9. Schnipper JL, Kirwin JL, Cotungo et al. Role of pharmacist counseling in preventing adverse events after hospitalization. Arch Intern Med 2006;166:565

10. Schnipper JL, Hamann C, Ndumele CD et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events. Arch Intern Med 2009;169:771

11. ASHP-APHA Medication Management in Care Transitions Best Practices 2013