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Evaluation of a Medication Reconciliation Process

Evaluation of a Medication Reconciliation Process. University of Maryland Medical Center Hospital for Children Baltimore, Maryland. Significance. 44,000 - 98,000 Americans die each year as a result of medical errors 8 th leading cause of death in the United States

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Evaluation of a Medication Reconciliation Process

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  1. Evaluation of a Medication Reconciliation Process University of Maryland Medical Center Hospital for Children Baltimore, Maryland

  2. Significance • 44,000 - 98,000 Americans die each year as a result of medical errors • 8th leading cause of death in the United States • More deaths than motor vehicle accidents, breast cancer, AIDS • Cost to hospital is $17 - $29 billion • Medicationerrors in our nation's 7,000 hospitals can cost as much as $15 billion per year • Accounts for approximately 7,000 deaths and over 770,000 injuries • 7/100 hospital admissions results in a medication error The Institute of Medicine Report To Err Is Human: Building a Safer Health System

  3. Research • 27% hospital prescribing errors attributed to incomplete medication histories upon admission • 67% medication histories erred (n=3755, 22 studies) • 11-59% clinically important (n=588, 6 studies) • 10-61% Omission Error • 13-22% Commission Error • 60-67% Omission or Commission Error • Pharmacist-initiated medication histories • Reduce mortality rate by 128 deaths per hospital annually • Saves an average of $7 million per hospital annually Tam, et al. CMAJ 2005;173(5):510-5 Beers MH, Munekata M, Storrie M. J AM Geriatr Soc. 1990;38:1183-7 Bond CA, Raehl CL, Franke T. Pharmacotherapy. 1999;19:556-64

  4. Objectives • Evaluate the current process for obtaining complete and accurate medication histories, checking drug interactions, identifying allergies, updating weight and immunization information within 24 hours of admission • Determine cost-savings for pharmacy interventions, evidenced by each potential adverse event avoided • Document and report adverse events associated with inaccurate or incomplete medication histories • Redesign and implement a standardized process for medication reconciliation across the continuum of care

  5. Methodology • Prospective, interventional quality improvement study • Evaluation of the traditional medication history process for inpatient admissions; excluding emergency department, unit transfers, hospital discharge, and outpatient clinic • Admissions to The University of Maryland Hospital for Children Pediatric Intensive Care Unit (PICU) or Intermediate Care Unit (IMC) • Expected duration of stay  24 weekday hours or  72 weekend hours • Involved pediatric patients and/or families who were able to provide medication histories

  6. Methodology • Current Process for Medication Reconciliation • Patients are accessed and triaged in Emergency Department • Inpatient admissions are interviewed by admitting physician • Physician documents patient-specific information and medication history on standardized admitting triage form • Nurse clarifies discrepancies or omissions within twenty-four hours of admission • Nurse documents information on a standardized nursing form • Upon inpatient unit transfer, all medications orders are rewritten by physician, and previous orders are discontinued by pharmacist in the pharmacy computer system • Daily MAR printed by pharmacy, and reflects pharmacy order entry • Upon patient discharge, pharmacy is occasionally contacted for patient education materials • No universally-accessible patient record updated with current home and discharge medications

  7. Phase I: Medication History Audit • Identify new inpatient admissions via PharmNet® census • Audit physician admitting triage form for incomplete medication histories • Document physician-obtained medication history on template form • Notify medical team of omissions in medical information

  8. Phase II: Interview and Intervention • Identify new inpatient admissions via PharmNet® census • Audit physician admitting triage form for incomplete medication histories • Interview patients and families within 24 weekday/72 weekend hours (2 attempts) • Document pharmacist-obtained medication history on template form • Notify medical team of discrepancies or omissions in medical information • Clarify discrepancies with help of patient and family • Document interventions in HealthProLink® • Assign a cost-savings for each intervention

  9. Phase II: Cost Analysis • $76 Allergy Info Clarified • $76 Allergy Prevented • $76 Dose Evaluation • $76 Drug-Drug Interaction • $76 Patient Medication History • $76 Patients Own Medications Evaluation • $76 Renal Dose Evaluation • $76 Therapeutic Duplication Avoided • $48 Therapeutic Interchange Done • $76 Weight Evaluated HealthProLink®

  10. Phase II: Cost Analysis • Cost of ADR ($2,500) • Difference in overall hospital cost for ADR $5,483 • ADR Prevalence (3%, 1/33 patients) • Prevalence of serious ADR 6.7% • Cost Savings through Intervention • $2,500/33 = $76/intervention/person • Therapeutic Interchange ($48 Average) • Assumes 3 days IV therapy avoided Suh DC, et al. In Ann Pharmacother 2000 Dec;34(12):1373-9 Lazarou, et al. JAMA 1998;279:1200-1205

  11. Results • Phase I • 42 charts audited/ 56 inpatient admissions • Age: 28 days – 20 years • Average time required for each chart audit: 5 minutes • Phase II • 46 charts audited/ 74 inpatient admissions • Age: 30 days – 19 years • Average time required for each chart audit: 5 minutes • Pharmacist-initiated patient interviews: 10 interviews • Average time required per interview: 5-15 minutes • Average time required per intervention: 1-60 minutes

  12. Results Total Number of Home Medications Number of Patients N=88

  13. Results Missing Patient Information Number of Charts N=88

  14. Results Missing Medication Information Number of Medications N=209

  15. Interventions • Overall cost-savings $8,126 • Total time required for interventions 11.92 hours • 128 interventions • Clarification of allergies/height/weight • Clarification of dosing/frequency/concentration • Formulary interchange • Patient counseling • Noncompliance assessment

  16. Interventions • 5 Adverse Events • 1000-fold overdose of clonazepam ordered, due to incorrect concentration on parent’s home medication list (0.1mg/ml vs. 100mg/ml) • 5-fold overdose of phenobarbital ordered, due to incorrect concentration per neurologist (20mg/5ml vs. 20mg/ml) • Acute withdrawal of medications due to abrupt discontinuation (fluoxetine, clonidine, quetiapine, dextroamphetamine/amphetamine) • Physician ordered corticotropin (Acthar® Gel) for treatment infantile spasm, however cosyntropin (Cortrosyn®) was dispensed x 3 days • Parents were administering furosemide and spironolactone as pre-medications for cardiac surgery; doses were exchanged

  17. Barriers and Limitations • Hospital Admission and Chart Access • Multiple hospital transfers • English language deficit • Patient absent for procedure, radiology, OR, ECT. • Missing H/P on single-day stay or surgical patient • Patient-Specific Limitations • Developmental age • Developmentally delayed • Cognitively compromised • Documentation Tool • Length of medication history form • Multiple documentation tools used by health care professionals • Paper-based process; universal access to information is delayed

  18. Barriers and Limitations • Admitting Patient Interview • Time required to thoroughly interview each new admission • Access to family or friends • Patient and family contact information missing, incorrect, or ineffective • Incomplete medical information • Incorrect medical information • Access to outpatient pharmacies and prescription history • Intervention • Time requirement for each medication clarification and intervention • Integration of intervention into patient medical record • Intervention • Universally-accessible electronic documentation tool • Integrate process into admission, unit transfer and hospital discharge

  19. Summary • Inaccuracies and omissions of medication histories leads to medication errors inpatient • The amount of time required to clarify medication discrepancies contributes to inefficient reconciliation • Documentation of medication clarifications is lacking • Documentation is not universally accessible • Pharmacy interventions contribute to completeness and accuracy of data, improves patient safety, and has added cost benefits • Obtaining complete and accurate medication histories requires a consistent, multi-disciplinary approach

  20. The Next Step • Multidisciplinary team of nurses, physicians, information technology staff, pharmacists, residents, medication safety representatives collaborating to improve medication reconciliation process over continuum of care • Determine procedural flow and responsibility for reconciling medication histories in ER and upon admission inpatient • Development of a patient-friendly medication reconciliation form, to be piloted in select inpatient units • Coordinate discharge planning and update documentation • Pilot medication reconciliation processes on paper • Integrate reconciliation tools and processes with POE database

  21. The Next Step • Pharmacy Involvement • Satellite-based pharmacy support; limited decentralized order entry • Participate in medication reconciliation process upon inpatient unit transfer • Current and accurate list of medications available to transferring physician on computer order entry system • Physicians prints active medication list, with option to “continue,” “continue with modifications,” or “discontinue” active medication upon unit transfer • Transfer medication list is faxed to pharmacy for order entry • New patient MAR printed for receiving nursing unit

  22. Background • Joint Commission on Accreditation of Healthcare Organizations National Patient Safety Goals • Goal 8 - Accurately and completely reconcile medications across the continuum of care • 8A - 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 • 8B - A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization Joint Commission on Accreditation of Healthcare Organizations, 2006 National Patient Safety Goals

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