Medication Reconciliation in the Medical Floor Medication Reconciliation in the Medical Floor A Patient Safety Quality Improvement Initiative A Patient Safety Quality Improvement Initiative

Medication reconciliation is defined as a formal process of obtaining a compete and accurate list of each patient’s current home medications (including name, dosage, frequency and route and comparing the physicians admission, transfer and/or discharge orders to that list.

The process involves:• Verification (collection of medication history)• Clarification (ensuring the medications & doses are appropriate)• Reconciliation (documentation of changes in the orders)

BackgroundBackground Key Steps continuedKey Steps continued Key Steps continuedKey Steps continuedKey Steps continuedKey Steps continued

Goals & ObjectivesGoals & Objectives

Key StepsKey Steps

Goal:• To develop and implement a Medication Reconciliation process that

incorporates the best possible medication history (BPMH) and facilitates timely and accurate admission/transfer/discharge orders.

Improvement Objectives:• To decrease the number of undocumented intentional and

unintentional discrepancies for patients admitted to the Medical Floor from ER by 75% by June 2007.

• To increase the number of BPMH completed by nurses, pharmacists, and physicians admitted to the Medical Floor by 75% by June 2007.

• Hospital admission, transfer and discharge are key medication-related vulnerable moments (history taking & ordering) where patients are at increased risk of medication discrepancies that potentially can lead to adverse drug events.

Figure 1. Summary of Process MapFigure 1. Summary of Process Map

Admission to Admission to Medical Floor Medical Floor

ICUICU

SurgicalSurgical

Vulnerable Vulnerable Moment #1Moment #1

Vulnerable Vulnerable Moment #1Moment #1

Vulnerable Vulnerable Moment #3Moment #3

Vulnerable Vulnerable Moment #3Moment #3

Vulnerable Vulnerable Moment #4Moment #4

Vulnerable Vulnerable Moment #4Moment #4

ERER ORORReturn to Return to Medical Medical

FloorFloorHomeHome

3. Baseline Data Collected – Audit Results3. Baseline Data Collected – Audit Results

Step 1Step 1Development of ProcessDevelopment of Process

Step 1Step 1Development of ProcessDevelopment of Process

Step 2Step 2Implementation of Implementation of

Med RecMed Rec

Step 3Step 3EvaluationEvaluation

Evaluation/DiscussionEvaluation/Discussion

Chart audits of 20 patients, revealed a mean Success Index of 75%. This is within the National Mean. This is prior to implementation of the Med. Rec. Process. Our goal is to improve our success index in 1 year by 75% of our baseline (95%). We will continue to monitor our success (on a monthly basis) using the same performance measurement.

We will continue to implement Medication Reconciliation, Test Results, Spread and Evaluate. We will know this change is an improvement using our 3 performance measures (compare future changes with current performance) and by measuring nursing satisfaction, physician satisfaction, pharmacy satisfaction & patient satisfaction.

Identified Potential Barriers to Success Include:• No clear owner of process, roles & responsibilities• Lack of understanding of potential impact• Use of various forms in various areas/no standardized process

Figure 6. Mean # of Undocumented Intentional Discrepancies (Type 2)Figure 6. Mean # of Undocumented Intentional Discrepancies (Type 2)

Figure 7. Mean # of Unintentional Discrepancies (Type 3)Figure 7. Mean # of Unintentional Discrepancies (Type 3)

ICU = Intensive Care Unit

ER = Emergency Room

Mean Number of Undocumented Intentional Discrepancies

00.20.40.60.8

11.21.41.61.8

Jun-06 Jul-06

TDH Mean #

TDH Goal

Ontario Node

National

Mean Number of Unintentional Discrepancies

0

0.5

1

1.5

2

2.5

Jun-06 Jul-06

TDH Mean #

TDH Goal

Ontario Node

NationalVulnerable Vulnerable Moment #2Moment #2

Vulnerable Vulnerable Moment #2Moment #2

Step 2Step 2Implementation of Implementation of

Med Rec (Pilot Med Rec (Pilot in Medical in Medical

Floor) Floor)

Step 1Step 1Development of ProcessDevelopment of Process

- Develop Team/FMEADevelop Team/FMEA- Design of tools Design of tools - Baseline data collectionBaseline data collection

Step 1Step 1Development of ProcessDevelopment of Process

- Develop Team/FMEADevelop Team/FMEA- Design of tools Design of tools - Baseline data collectionBaseline data collection

Step 3Step 3EvaluationEvaluation

-AuditsAudits-Success IndexSuccess Index-Hospital-wide roll outHospital-wide roll out

Table 1. Summary of Failure Mode Effects AnalysisTable 1. Summary of Failure Mode Effects Analysis

Figure 2. Project PlanFigure 2. Project Plan

Table 2. Failure Mode SummaryTable 2. Failure Mode Summary

Figure 3. Best Possible Medication History-Baseline Audit ToolFigure 3. Best Possible Medication History-Baseline Audit Tool

Figure 4. Automated Discharge Prescription (Meditech)Figure 4. Automated Discharge Prescription (Meditech)

2. Tools Developed 2. Tools Developed

Hospital InformationHospital Information

Complete List of Complete List of MedicationsMedications

Physician Name Physician Name & Signature& Signature

Patient ReminderPatient Reminder

Patient InformationPatient Information

Figure 5. Automated Discharge Summary (Meditech)Figure 5. Automated Discharge Summary (Meditech)

No Need to Dictate No Need to Dictate Medications – Medications – Information Flows Information Flows Through to Through to Discharge SummaryDischarge Summary

1. Failure Mode Effects Analysis1. Failure Mode Effects Analysis

Disseminated information through Disseminated information through various mediumsvarious mediums

• Presentations to TDH Quality Council, Hospital Board, pharmacists, program core team, staff meetings

• Inservices to Medical Floor Resource Nurses outlining process for completing a BPMH & medication reconciliation• Media campaign (newspaper & television)• Signage & email

Figure 8. Medication Reconciliation Success Index Figure 8. Medication Reconciliation Success Index (Pre-Implementation)(Pre-Implementation)

Medication Reconciliation Success Index

0%10%20%30%40%50%60%70%80%90%

100%

Jun-06 Jul-06

TDH Mean #

TDH Goal

Ontario Node

National

Patient Safety Committee, 2006