The Medication Reconciliation

Dilemma
May 24, 2007

Eric E. Howell, MD
Assistant Professor of Medicine
Johns Hopkins University, School of Medicine
Johns Hopkins Bayview Medical Center

Brian Clay, MD
Assistant Professor of Medicine
Division of Hospital Medicine
UC San Diego
 Objectives:
Learn the impact of medication
reconciliation (or lack thereof) on patients
Identify the potential weaknesses in
current medication reconciliation
processes
Demonstrate a knowledge of current
options, option strengths and option
limitations
 Outline for Today
Setting the stage
Review the Data
SHM Survey (Brian Clay)
JHBMC Med Rec Experience
Discuss Resources Available
Conclusions
Discussion
Adverse Drug Event (ADE) Case
Files*
80 y.o. man admitted from home to hospital

Meds changed, including start of “ramipril”

On DC summary amaryl listed, not ramipril

Physician did not reconcile meds on DC

* http://www.dhmh.state.md.us/
 ADE Case Files*

Pt discharged

Later he is found obtunded

Found to be hypoglycemic and readmitted

Pt died a few days later from injuries

* http://www.dhmh.state.md.us/
 What Happened?
Swiss Cheese Model of Major Errors
Amaryl
Outpt DC meds not reviewed transcribed
doc Admission
unaware
of
change

Sentinel
Event Pt/care giver does not
review meds

Reason J. Human error: models and management. BMJ. 2000;320:768-770.

 Background on Adverse Events
(AE) and ADEs
Recall that ~ 20% of pts have AE on DC1,2
Most AEs are Preventable or Ameliorable
(about 1/3 for each)

Majority (66-72%) of AEs are ADEs

1) Forester, Arch Int Med. 2006;166:565-71

2) Forester, Ann Intern Med. 2003;138:161-167
 ADEs are Common!
As early as 1995 ADEs thought to be1 :
Common- 6.5%
Preventable- up to 42%
Studies continue to support ADEs as 2,3,4:
Common- 11%
Preventable (Ameliorable)- 27% (33%)

1) Bates, JAMA. 1995;274:29-34.

2) Forester, JGIM. 2005;20:317-23
3) Forester, CMAJ. 2004;170:345-9
4) Schnipper, Arch Intern Med. 2006;166:565-71
How Can ADEs Be Reduced?

Adverse Drug Events are reduced when

medications are explained (reviewed)1,2,3

1) Bates, JAMA. 1995 Jul 5;274(1):29-34.

2) Schnipper, Arch Intern Med. 2006 Mar 13;166(5):565-71
3) Forester, Arch Int Med. 2006;166:565-71
 IOM: To Err is Human
1999- Institute of Medicine’s (IOM) report
98,000 deaths annually in hospitals
1.5 Million Potential ADEs (1/day/pt)
9000 deaths from adverse drug events

Most errors are system based, not due to

reckless individuals

http://www.nap.edu/openbook.php?isbn=0309068371
 Background
The IOM report and other data spur
action by the Institute for Healthcare
Improvement (IHI):
6 changes that save lives
Deployment of Rapid Response Teams…at the
first sign of patient decline
Delivery of Reliable, Evidence-Based Care for
Acute Myocardial Infarction…to prevent deaths
from heart attack
Prevention of Adverse Drug Events (ADEs)…by
implementing medication reconciliation
Prevention of Central Line Infections…by
implementing a series of interdependent, “Some is not a number; soon is not a time”
scientifically grounded steps called the “Central
Line Bundle”
Prevention of Surgical Site Infections…by
reliably delivering the correct perioperative
antibiotics at the proper time
Prevention of Ventilator-Associated
Pneumonia…by implementing a series of
interdependent, scientifically grounded steps called
the “Ventilator Bundle”
 Background
The IOM report and other data spur
action by the Institute for Healthcare
Improvement (IHI):

Prevention of Adverse Drug Events (ADEs)…by

implementing medication reconciliation

“Some is not a number; soon is not a time”

 Institute for Healthcare
Improvement (IHI)
Reconciliation: 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
Requires comparing the patient’s list of current
medications against the physician’s admission,
transfer, and/or discharge orders

http://www.ihi.org/NR/rdonlyres/598D427A-4BDA-419D-91B5-
B836D23A6F1D/0/CampaignOverview101105.ppt#358,9,Prevent Adverse Drug Events by Implementing Medication
Reconciliation
 Background
The IOM report and other data spur
action by the Joint Commission:
2005 patient safety Goals:

Goal 8:
Accurately and completely reconcile medications across the
continuum of care.
Goal 8A:
During 2005, for full implementation by January 2006,
develop 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.
Goal 8B:
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.
 Joint Commission (JC)
Medication reconciliation is 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.
This process comprises five steps: 
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient.

•http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/05_hap_npsgs.htm
 Joint Commission (JC) Data
2005 Develop Process for Medication
Reconciliation
Compliance:
99.7%+
2006 Full implementation of Med
Reconciliation
Compliance:
62%
 2006 SHM Meeting
Medication Reconciliation Survey
Brian Clay, MD
Assistant Professor of Medicine
Division of Hospital Medicine
UC San Diego
 2006 SHM Meeting
Medication Reconciliation Survey
Survey placed in all attendees meeting
materials (approximately 800)
Questions regarding demographics,
institutional characteristics, process steps,
and barriers to implementation
295 surveys returned
 2006 SHM Meeting
Medication Reconciliation Survey
Majority (90%) of institutions represented
served adult population
Multiple hospital types represented
– Academic tertiary care center (23%)
– Community teaching hospital (29%)
– Private community hospital (43%)
 2006 SHM Meeting
Medication Reconciliation Survey
Implementation stage varied
– Fully implemented (48%)
– Partially implemented (35%)
– Still in planning stages (11%)
Hospitalist involvement varied
– Active role in design/implementation (36%)
– Peripheral role/consultation (24%)
– Not involved (31%)
 2006 SHM Meeting
Medication Reconciliation Survey
Format
– Paper (47%)
– Computer (11%)
– Combined (31%)
Measurements
– Measuring compliance (42%)
– Measuring outcomes (22%)
 2006 SHM Meeting
Medication Reconciliation Survey
Process Steps
– Physician roles
Reconciling medications
Updating discharge medication list
Communicating med information to next provider
– Nursing or “shared” (RN/MD) roles
Obtaining home medication list
Documenting home medication list
Providing discharge med information to patient
 2006 SHM Meeting
Medication Reconciliation Survey
Barriers to Implementation
– Patients do not know medications (87%)
– Medication list not available (80%)
– No access to outside records (63%)
– Formulary differences (59%)
– Process takes too long (53%)
– Hospital systems are cumbersome (52%)
Potential impact
– 58% of those surveyed feel medication
reconciliation will have a positive impact
 2006 SHM Meeting
Medication Reconciliation Survey
Community teaching hospitals and private
hospitals more likely to have med recon
implemented compared to academic
centers (57%, 49% vs. 35%, p = 0.007)
However, academic centers more likely to
use computer systems to do med recon
(27% vs. 9%, 7%, p = 0.005)
 2006 SHM Meeting
Medication Reconciliation Survey
Obtaining and documenting pre-admission
medications
Academic centers: more a physician
responsibility
Community teaching hospitals and private
hospitals: more a nursing responsibility
Most common response was a “shared”
responsibility
 2006 SHM Meeting
Medication Reconciliation Survey
Reconciling medications with admission
orders
– Physician responsibility at all sites
Striking lack of pharmacist involvement
– Obtaining/documenting meds: 5%
– Reconciling meds: 6%
– Discharge instructions: 2%
 2006 SHM Meeting
Medication Reconciliation Survey
Conclusions
– “Shared” responsibility model is common
– Multiple barriers to full implementation
– Underutilization of pharmacists
– Hospitalists have played a prominent role in
design and implementation
Much more opportunity for hospitalist leadership in
this area
Johns Hopkins Bayview

Medication Reconciliation
Dilemma
 JHBMC and the Medication
Reconciliation Dilemma
2004:
– Just starting to address issue
– Faculty & staff unaware/uninterested in
problem
– JHBMC did a FEMA: Improve work flow
through paper tools
 JHBMC and the Medication
Reconciliation Dilemma
2004-2005:
– Hospital leadership partners with several
cooperative physicians to “champion” cause
– Hospital leadership engages physician
leadership, get buy-in on problem
– Interdisciplinary meetings begin
– New paper process simplifies and streamlines
med-rec process
 JHBMC and the Medication
Reconciliation Dilemma
Process has:
– Admit sheet to list outpt meds
– DC Sheet with:
Place designating meds “reconciled”
Check boxes for “no change”, “stop” and “new”
Check box to designate pt education occurred
– Sheets “side-by-side” capability
 JHBMC and the Medication
Reconciliation Dilemma
Paper discharge list an instant success
Admit sheet for meds used intermittently
Need both components to be successful

Bottom Line:
Developing process was easy,
multiple barriers made implementation hard
 Overcoming Barriers: PDSA
Got stakeholders together
Identified Barriers:
Form not in chart
Avg doc not engaged
Pt health literacy
Took extra doc time
Popular H&P “med list” used
modified from: The Foundation of Improvement by Thomas W. Nolan et.
al
 Overcoming Barriers: PDSA
Identified Barriers: Developed Solution:
Form not in chart  Educated Unit Sec’s
Avg doc not engaged  QI team showed data met
freq
Pt health literacy  XXXX
Took extra doc time  Improved w/avail forms
Popular H&P “med list”  Placed big “USE MED REC
LIST” sticker over H&P
med area!

SUCCESS!
JHBMC Future Direction: Electronic
Medication Reconciliation
 JHBMC Future Directions
Current electronic format has potential:
– “Ambulatory list” can be selected for in-pt use
– Admission/hospital/discharge meds on one
screen
– May condense “duplicate” lists: nursing & MD
 JHBMC Future Directions
Current electronic format drawbacks:
– Lists are not “side-by-side” making
reconciliation challenging: Structure of
electronic format does not always facilitate
workflow
– Not sure how admission list will get populated
– Docs still using H&P to document meds??
 Resources Available

http://macoalition.org/

JC’s Dr. Croteau (executive director for pt safety

initiatives) reports JC gets “information and
support” from the macoalition
 www.hospitalmedicine.org

Information in the SHM “resource rooms”

http://macoalition.org/Initiatives/RMTool
kit.shtml
Implementation Guide for Safe Practices
(A Resource Book of Materials)
Overview
Safe Practice Recommendations
Implementation Strategies
Toolkits
RUN DATE: Holyoke Hospital LIVE ADM PAGE 1
RUN TIME: MEDICATION RECONCILIATION FORM
RUN USER:
LOCATION: NAME: ACCOUNT NO:
ROOM-BED: AGE/SEX: ADMITTED MEDICAL RECORD NO:
ATTENDING:

ADMISSION ASSESSMENT

DRUG DOSE ROUTE FREQ Written on MD Result of

Admission Contacted MD Contact:
Med Ordered

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No

Additional information:
Herbal/Homeopathic remedies:
Disposition of patient's medications upon admission:

Comments: (If MD did not order med after call/notification - - state why) _______________

_______________________
Nurse's Signature
ATTENTION PHYSICIAN
Please Reconcile Meds
 PATIENT NAME:

UNIT NUMBER:

PREADMISSION MEDICATION LIST

VERIFICATION AND ORDER FORM
(Medication Reconciliation)

Allergies:

LIST BELOW ALL OF THE PATIENT’S MEDICATIONS PRIOR TO ADMISSION INCLUDING OTC AND HERBAL MEDS
NEW MEDICATIONS OR MEDICATION CHANGES SHOULD BE WRITTEN ON ADMISSION ORDERS
Source of Medication list: (check all used)
CHECK HERE IF THIS IS AN ADDENDUM TO OR
Patient medication list
REVISION OF PREVIOUSLY COMPLETED
Patient/Family recall
Pharmacy _________________ MEDICATION LIST
Primary care physician list / PCHIS
Previous discharge paperwork CIRCLE C to continue OR
Medication Administration Record from facility DC to discontinue
Other: _______________________________
MEDICATION HISTORY RECORDED/VERIFIED BY : _____________________ PHYSICIAN PHYSICIAN
DATE RECORDED: _________________________________ ORDER ORDER
ROUTE Continue Continue COMPLETE
MEDICATION NAME DOSE LAST DOSE
(PO, GT, FREQUENCY on on On
(WRITE LEGIBLY) (mg, mcg, ) DATE/TIME
SC, IV) Admission Transfer Discharge

1. C DC C DC
2. C DC C DC
3. C DC C DC
4. C DC C DC
5. C DC C DC
6. C DC C DC
7. C DC C DC
8. C DC C DC
9. C DC C DC
10. C DC C DC
11. C DC C DC
12. C DC C DC
13. C DC C DC
14. C DC C DC
15. C DC C DC
Do not scan or take off orders without MD/NP/PA signature

M.D. Signature:____________________________________ Print Name:_______________________________________________

Pager: Date/Time:
Reviewed and Transcribed
Nurse Signature:____________________________________ Date/Time:________________________
Caritas Norwood Hospital Patient Label
Norwood, MA Medication Reconciliation Form
Please complete form to list all medications identified by the patient, family, written medication list, available prescription vial(s).

Drug Allergy: Reaction: Drug Allergy: Reaction:

Drug Allergy: Reaction: Drug Allergy: Reaction:

Prescription (Rx) and Over-the-Counter (OTC) Medications

Ordered on Results of MD
Time of Admission exactly Check box to identify field consult: Comments/
last dose as documented discrepancy Med ordered changes
prior to If No, contact MD clarified
Medication Dose Route Freq admission Yes No Med Dose Rte Freq Yes No
 COOLEY DICKINSON HOSPITAL
TEST FORM: PREADMISSION
MEDICATION LIST VERIFICATION

Allergies:

List all of the patient’s medications Prior to Admission including OTC and Herbal preparations.
Date Recorded:
Continued on
Medication Name
Dose Route Frequency Last Taken Admission?
(Write Legibly)
Y or N
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Nurse Comments:

Nurse Signature:

Sources of Information (check all applicable): I have reviewed this list:

 Patient’s own medication list
 Patient/Family recall
 Pharmacy (name & phone):
 Physician’s list (name): Physician Signature Date
 Prior hospital records (name facility)
 Other (specify):

Alternate Providers  No  Yes: List__________________________________________________________

What do most med recon forms
have in common?
Some indication that the medication was
“reconciled”
A list of potential sources for the list (patient,
records, etc)
A way to indicated that specific medications
were changed from admission
Separate spaces for med, dose, route, freq, time
last taken
Most have started with an existing model and
modified it for their institution’s needs
 www.hospitalmedicine.org

Information in the SHM “resource rooms”

Toolkits
QI Educational Material
 SHM Resource Rooms
Toolkits:
Sample Forms
 SHM Resource Rooms
Toolkits:
Sample Forms
Workbook on implementation
 SHM Resource Rooms
Toolkits:
Sample Forms
Workbook on implementation
Web Community (ask the expert)
 SHM Resource Rooms
Excellent QI Overview:
Very thorough Slide Show
 SHM Resource Rooms
Excellent QI Overview:
Very thorough Slide Show
Extensive workbooks on how to effect change
A Few words about QI…
Sound QI principles make success much,
MUCH more likely!

Consider doing a FEMA

 A Few Words About FEMA

Process Step Process Step Process Step Process Step

1 2 3 4

Failure Mode Failure Mode Failure Mode Failure Mode

Failure Mode Failure Mode Failure Mode Failure Mode

Failure Mode Failure Mode Failure Mode Failure Mode

Failure Mode Failure Mode Failure Mode Failure Mode

A Few (more) Words about QI…
Engage Administration
This is a team effort
Don’t let perfection stand in the way of
good
Measure and change based on the
outcomes
 Summary
Medication Reconciliation has significant
potential to improve patient safety
Medication Reconciliation is complex!
Electronic solutions still in infancy
Implementation require sound QI methods
– Physician champion
– Well coordinated team effort (including physician)
– Rapid cycle change (PDSA)
– Evaluation method
 Summary
Don’t re-invent the wheel, lots of good stuff
out there already
Don’t let perfection get in the way of good
I have heard that surveyors raise the bar
over time!
 Other Resources
Joint Commission Web link:
http://www.jointcommission.org/

IHI weblink:
http://www.ihi.org/ihi
 More to Come….

Medication Reconciliation Conference in the Works

New Medication Reconciliation Survey due out soon