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© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Medication Reconciliationin Long Term Care
Atlantic Node Collaborative
Margaret Colquhoun
SHN Intervention Lead
Sept. 2008
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
ISMP Canada
Mission:
To identify risks in medication use systems, recommend optimal system safeguards and advance safe medication practices.
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Medication Reconciliation in LTC
Goal: Reduce the potential for adverse drugs events (ADEs) by identifying and resolving discrepancies and improving documentation in drug regimens at LTC care
transitions
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Background
Incomplete/inaccurate medication information is reflected in growing number of LTC studies.
Alberta 2007:• 75% medication information was NOT
legible/complete • 90% information was NOT available to tell
prescribed medications appropriate for diagnoses.
• 40% medication information DID NOT arrive the same day as the resident’s admission.(1)
• [1] Earnshaw, K et. al. Perspectives of Alberta Nurses and Pharmacists on Medication Information Received. July 29, 2007
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Background
• 2004 study “incidence of ADEs caused by medication changes at transfer between facilities was 20%.
• Most on transfer from acute to LTC
• Incomplete/inaccurate communication a factor
Broockvar K, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and Long-term care facilities. Arch Intern Med.
2004;164:545-550
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
True Story…
• Patient admitted for investigation of recent onset of jaundice
• Levothyroxine daily not ordered – missed for 3 weeks
• Returned to LTC with symptoms of hypothyroidism
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Another…
• Admission from LTC with urosepsis successfully treated
• Three chronic medications not continued during acute care stay
• On transfer back to LTC experienced acute attack of gout secondary to furosemide use/not receiving allopurinol
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Medication reconciliation in LTC
• A formal process of:
• At admission, creating a complete list of resident’s current and pre-admission medications – including name, dosage, frequency and route (BPMH).
• Using the BPMH to create admission orders or comparing the list against the resident’s admission orders, identifying and bringing any discrepancies to the attention of the prescriber for resolution.
• Documenting any resulting changes and communicating to relevant providers
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Sounds Easy Right?
Complex interplay of documentation and cognitive
tasks
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
What’s so Different?
Lengthy stays
Treatment includes many medications• Average 9.8 meds, up to 12.7 meds including prn
Care by fewer professional staff• Limited on-site pharmacist time
• Variable availability of physicians
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Terminology
• Best Possible Medication History (BPMH) - A current medication history includes all regular medication use
• Training
• Multiple sources of info
• BPMH compared to admission orders to identify discrepancies
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Terminology
• Undocumented Intentional discrepancy is one in which the prescriber has made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented.
• Unintentional discrepancy is one in which the prescriber unintentionally changed, added or omitted a medication the resident was taking prior to admission.
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Terminology
• Most Current Medication List – The most recent list of medications (name of medication, dose, route and frequency) currently taken by the resident – Used for medication reconciliation at discharge
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Core Measures
Mean number of UNDOCUMENTED INTENTIONAL Discrepancies (Documentation Accuracy)
Target: Reduce baseline by 75%.
Mean number of UNINTENTIONAL Discrepancies (Medication Error)
Target: Reduce baseline by 75%.
Percentage of Residents Reconciled upon admission
Target: 100% of residents at admission.
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Keys to Implementation
• Secure leadership commitment/involvement• Project plan (map current process)• Educate staff:
• Why medication reconciliation?• How to reconcile• BPMH training
• Develop and test new process• Embed process so that it becomes “the way you
do things”• Measure & sustain the improvements you have
made• Spread to other areas / populations
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Considerations
• Proactive vs reactive
• Admission, transfer, discharge
• Different disciplines
• Institution specific
• NOT about a form
• Engage patient & family
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Supports
• GSK
• Atlantic node collaborative
• National calls
• Community of Practice – LTC section
• National Learning Series
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Getting Started KitMedication Reconciliation in
Long-Term Care
• Step-by-step guide to the process
• Model for Improvement
• Tools and Tips
• Samples
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Communities of Practice
SHN Website – Critical Success Factors: Education
• Standardize material
• Make use of “teaching” moments
COP – Critical Success Factor: Communication
• Speak language of audience
• Preparation and follow-up are critical
• Show-off your results
• Use your stories!!!!
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
Acute Care Learning
• Data, results, stories • Training• Leadership• One size does not fit all• Is a clinical function• Requires resident/family participation• Use different health disciplines
appropriately• Commitment!!
© Institute for Safe Medication Practices Canada 2008®© Institute for Safe Medication Practices Canada 2008®
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