*Pharmacists could pick as many barriers as applicable

The collection of a Best Possible Medication History (BPMH) is the basis for safe prescribing

In an ambulatory oncology setting, the BPMH is required to check for drug interactions with any new medication being initiated and to complete the medication reconciliation process

As more cancer therapies are delivered through the oral route, Cancer Care Ontario has recognized the importance of collecting a BPMH to ensure these potentially toxic medications are administered safely1

Models for collecting and documenting the BPMH as well as performing medication reconciliation are not well defined in the ambulatory care setting

Implementing a systematic way to identify patients requiring the collection of a BPMH, determining the frequency of BPMH collection and medication reconciliation and how changes will be communicated to other providers is a documented Accreditation Canada 2015 Standard2

BACKGROUND

At the Sunnybrook Odette Cancer Centre (OCC) Pharmacy our baseline BPMH completion rate for patients starting a new Oral Anticancer Medication (OACM) was low at 28%, and this was seen as potential for serious medication incidents

We needed to develop a Standard Operating Procedure (SOP) for how and when patients will have a BPMH collected at the OCC Pharmacy and a way to measure compliance with this procedure

AIM: To increase the BPMH completion rate at the OCC Pharmacy to 100% for all patients starting a new OACM

QUALITY IMPROVEMENT PROBLEM

We asked frontline pharmacists working at the OCC Pharmacy to complete a Baseline Pharmacists’ Needs Assessment Survey (Table 1) to collect qualitative data on the barriers to completing a BPMH during the patient counseling session on a new OACM

An experienced oncology technician was hired as the BPMH technician and trained in the systematic collection and central documentation of comprehensive medication histories using the Sunnybrook BPMH Module and hands-on training with the Oral Chemotherapy Pharmacist

A Standard Operating Procedure (SOP) for the completion of BPMHs for patients starting an OACM was created and implemented at the OCC Pharmacy

This SOP was also shared with frontline nurses and medical oncologists so they would know what to expect from the pharmacy team

METHODS

S. Singh RPhT1, F. Charbonneau RPh1, A. Thawer RPh1

1Department of Pharmacy, Odette Cancer Centre, Sunnybrook Health Sciences Centre

Barrier* Pharmacists’ Assessments (N=12)

Lack of time 12 Patient feeling overwhelmed 11 Need to focus on drug education 7

Not familiar with documentation system 2

Language barrier 2 Lack of counseling space / computers 1

Patients are in a rush / don’t know their medications 1

Figure 2: SOP for Collection and Documentation of BPMH for new OACM patients

1. Cancer Care Ontario. Quality Person-Centered Systemic Treatment in Ontario: 2014-2019 systematic treatment provincial plan. Last updated: n/a. Accessed on October 6, 2015 at https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=325326

2. Accreditation Canada. Required Organizational Practices: Handbook 2015. Last updated: 2015. Accessed on October 6, 2015 at http://www.accreditation.ca/sites/default/files/rop-handbook-2015-en.pdf

REFERENCES Figure 3: Improvement in BPMH collection and documentation rates

Assignment of a dedicated technician to BPMH tasks led to a higher rate of completion.

BPMHs were collected while patients were waiting for their medication to be prepared so counseling sessions could be shorter and focus only on drug education.

Practitioners preferred having the BPMH completed over the phone and a drug interaction check performed prior to the patient even arriving at the pharmacy, allowing proactive discussion with the prescriber regarding needed changes.

WHAT WORKED?

Sustainability is at risk when the BPMH technician is on vacation or away from the pharmacy. A contingency plan that addresses cross-training needs to be built into the SOP.

The process, being somewhat new, relies on dispensary pharmacists to remember to page the BPMH technician for a new OACM patient. An automated process would be ideal.

Explore methods to enable physicians to notify pharmacy of plans to initiate OACM for specific patients. This would facilitate conduction of the BPMH and interaction check prior to the patient arriving in pharmacy and expecting to imminently start the medication.

WHAT NEEDS WORK?

Currently, the BPMH is documented in the electronic patient record but the identification of drug interactions and the outcome of those drug interactions (i.e. medication discontinuation, or dose adjustment) is not documented. We need to work with the IT department to ensure this is a feature of the electronic record.

The SOP needs to be expanded to include medication reconciliation. The updated BPMH should be shared with other members of the patient’s healthcare team: community pharmacist, family physician and any other required practitioner.

NEXT STEPS

RESULTS Table 1: Results from Baseline Needs Assessment Survey

Pathway includes procedure when technician is given advance notice or when immediate collection is required.

BPMH technician cross checks home medications with new OACM through an interaction database and alerts the pharmacist to any potential issues requiring discussion with prescriber prior to dispensation and counseling.

BPMH completion rate was 28% prior to SOP implementation SOP and dedicated BPMH technician resulted in a 90%

completion rate in an 8 month period.

Baseline Pharmacists’

Needs Assessment

Survey Conducted

BPMH technician hired and

trained

SOP for BPMH completion created and implemented

Figure 1: Summary of Methods

Patient identified by receiving email from social worker, OACM pharmacist or physician

BPMH technician paged to pharmacy, when patient has arrived to receive new oral chemotherapy

Gather information from multiple sources: ODB profile viewer, community

pharmacy, EPR

Complete BPMH and interview patient or family member

Enter BPMH in electronic medical record

Check for interactions using Lexicomp. Any interactions found?

Notify pharmacist regarding the interaction. Pharmacist to determine appropriateness of medication.

YES NO

ADVANCE STAT

28%

82%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan 2-Feb 17 2015 Apr 28-May 14 2015 Sept 1-Sept 30 2015

% P

atie

nts

with

BP

MH

in E

lect

roni

c R

ecor

d

Prepare prescription for dispensing; patient to be counseled by a pharmacist