Medication Reconciliation

1. Medication Reconciliation The content of this presentation is the property of the Joint Commission International Commission on Patient Safety. For reference only. No part of this presentation is to be republished without permission.

2. Carol Wagner Executive Director, Patient Safety WSHA Steven M. Riddle,BS Pharm, BCPS Lead Pharmacist, Medication Utilizationand Quality ImprovementHarborview MedicalCenter Sharon I. Eloranta, MD Qualis Health Presenters Richard J. Croteau, MD Executive Director for Patient Safety InitiativesJoint Commission International Commission for Patient Safety

3. Outline • Importance of medication reconciliation for patient safety • Requirements and survey process • Key steps and effective strategies • Best examples from around the country

4. Sentinel Event Experience to Date Of 3548 sentinel events reviewed by the Joint Commission, January 1995 through December 2005: 464 inpatient suicides 455 events of surgery at the wrong site 444 operative/post op complications 358 events relating to medication errors 269 deaths related to delay in treatment 189 patient falls 138 deaths of patients in restraints 121 assault/rape/homicide 109 perinatal death/injury 94 transfusion-related events 67 infection-related events 66 deaths following elopement 65 fires 58 anesthesia-related events 651 “other” = 3548 RCAs

5. Potassium chloride Policy issues Policy issues Policy issues Policy issues Wrong site surgery Suicide Restraint deaths Infant abductions Transfusion errors High Alert Medications Op/post-op complications Impact of SE Alert Fatal falls Infusion pumps Proactive risk reduction Home fires (O2 therapy) Kernicterus Look-alike, sound-alike drugs Kreutzfeldt-Jakob disease Medical gas mix-ups Needles & sharps injuries Dangerous abbreviations Wrong-site surgery #2 Ventilator-related events Delays in treatment Bed rail deaths & injuries Nosocomial infections Surgical fires Perinatal deaths Anesthesia awareness Kernicterus #2 PCA by proxy Intrathecal vincristine Medication reconciliation Wrong route / wrong tube Sentinel Event Alert

7. National Patient Safety Goals • Each year, a set of Goals will be identified from topics published in Sentinel Event Alert • A small number of specific requirements for each of the Goals will be identified for survey the following year

8. National Patient Safety Goals • The Goals and their requirements will be published by mid-year • Selection of the Goals and requirements will be guided by a panel of experts: the Sentinel Event Advisory Group

9. The Joint Commission 2006National Patient Safety Goals • Patient identification • Communication among caregivers • Medication safety • Wrong-site surgery Universal Protocol • Infusion pumps • Clinical alarm systems • Health care-associated infections • Medication reconciliation • Patient falls • Flu & pneumonia immunization • Surgical fires • NPSG implementation by network components • Patient involvement • Pressure ulcers

10. The JCAHO 2006National Patient Safety Goals Goal #8: Accurately and completely reconcile medications across the continuum of care.

11. The JCAHO 2006National Patient Safety Goals Requirement #8.a. • Implement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.

12. The JCAHO 2006National Patient Safety Goals Requirement #8.b. • A complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

13. Why Is Medication Reconciliation Important? • The most frequently occurring type of medical error: • Medication errors • The most frequently cited category of root causes for serious adverse events: • Ineffective communication • The most vulnerable parts of a process: • Links between the steps (the “hand-offs”) • Medication reconciliation addresses all of these

14. Prescription medications Sample medications Vitamins Nutriceuticals Over-the-counter drugs Vaccines Diagnostic and contrast agents Radioactive medications Respiratory therapy-related medications Parenteral nutrition Blood derivatives Intravenous solutions (plain or with additives) Any product designated by the FDA as a drug “Medications” Include:

15. Steps in the Reconciliation Process • Develop a complete and accurate list of the patient’s medications • Compare (reconcile) the listed medications with any new orders for medications • Omission • Duplication • Interaction • Name/dose/route confusion

16. Steps in the Reconciliation Process • Update the list as orders change during the episode of care • Communicate the updated list to the next provider(s) of care (See PC.15.10—PC.15.30)

18. When Should Reconciliation Occur? • Whenever the organization …“… refers or transfers a patient to another setting, service, practitioner, or level of care within or outside the organization.”

19. When Should Reconciliation Occur? • At a minimum … • Any time the organization requires that orders be rewritten • Any time the patient changes service, setting, provider or level of care and new medication orders are written • For transitions not involving new medications or rewriting of orders, the organization determines whether reconciliation must occur.

20. Where Should Reconciliation Occur? • Goal #8: Accurately and completely reconcile medications across the continuum of care. • Includes all settings of care and any transitions between them … whenever medications are used. • Inpatient • Outpatient • Emergency department • Imaging services

21. Whose list is it, anyway? Requirement #8.b. • A complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

22. Whose list is it, anyway? What’s on the list? • All the medications the patient is to be taking after discharge, including dosage, frequency, and route. Who gets the list? • The next provider of care • The patient

23. Discharge Orders, Instructions, Lists Discharge orders: • Directed to other caregivers (treatments, Rx) • Blanket orders (“resume all …”) are prohibited Discharge instructions: • Directed to the patient (self-care) • “Resume home meds” is permitted

24. Discharge Orders, Instructions, Lists Discharge list of medications: • Complete list of continuing medications • This is not an order; previous medications do not need to be reordered

27. For more information: The Joint Commission Web Site: www.jcaho.org Joint Commission International Web Site: www.jcrinc.com Joint Commission International Center for Patient Safety: www.jcipatientsafety.org My e-mail address: rcroteau@jcaho.org

28. Questions?

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