© 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.
© Institute for Safe Medication Practices Canada 2009® Slide 3
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
© Institute for Safe Medication Practices Canada 2009® Slide 4
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
© Institute for Safe Medication Practices Canada 2009® Slide 8
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
© Institute for Safe Medication Practices Canada 2009® Slide 9
Medication Reconciliation Medication Reconciliation at Internal Transferat Internal Transfer
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
© Institute for Safe Medication Practices Canada 2009® Slide 11
Medication Reconciliation Medication Reconciliation at Internal Transferat Internal Transfer
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).
© Institute for Safe Medication Practices Canada 2009® Slide 12
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
© Institute for Safe Medication Practices Canada 2009® Slide 13
National Transfer Medication National Transfer Medication Reconciliation Team DescriptionsReconciliation Team Descriptions
Wong C et al. UHN/ ISMPWong C et al. UHN/ ISMP
© Institute for Safe Medication Practices Canada 2009® Slide 14
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
© Institute for Safe Medication Practices Canada 2009® Slide 15
National Snapshot Of Transfer National Snapshot Of Transfer Medication ReconciliationMedication Reconciliation
Wong C et al. UHN/ ISMPWong C et al. UHN/ ISMP
© Institute for Safe Medication Practices Canada 2009® Slide 16
Transfer: Clinicians Primarily Transfer: Clinicians Primarily ResponsibleResponsible
Wong C et al. UHN/ ISMPWong C et al. UHN/ ISMP
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
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
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.
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.
© Institute for Safe Medication Practices Canada 2009® Slide 47
Common Challenges and Strategies in Internal TransferCommon Challenges and Strategies in Internal Transfer
© Institute for Safe Medication Practices Canada 2009® Slide 48
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