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This session will introduce delegates to medicines reconciliation and its role in reducing the opportunity for error and harm to patients by making sure they are given the right medicines at every stage of their care.
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Medicines Reconciliation Needs YOU!
Jennifer Ross Medication Safety OfficerSPSP Fellow
Aims:• For everyone to enjoy the session and participate.• To provide a general introduction to medicines
reconciliation.• To consider the patient journey as a process.• To establish the role of medicines reconciliation in
reducing avoidable harm.• To demonstrate how FMEA as an improvement tool
can improve the quality of a process. • Delegates will have an understanding of FMEA and
have a plan of how they will use it to improve medicines reconciliation for patients.
What is Medicines Reconciliation?
‘the process of identifying the most accurate list of a patient’s current medicines — including the name, dosage, frequency, and route — and comparing them to the current list you are working from. This enables any discrepancies to be recognised and changes documented, thereby resulting in a complete list of medications, accurately communicated.’
Institute of Health Improvement
Group work 1.
Consider Mr CeeCee’s Journey and work out how many transitions occur where Medicines reconciliation should have been done. You have 5 minutes to introduce yourselves at your table and decide as a group how many times medicines Reconciliation should have been undertaken.
Patient Journey as a process.Patient is admitted to A&E due to a collapse whilst out shopping
Patient is transferred to community hospital
Discharged home
Patient is stabilised and transferred
to acute assessment Unit.
Patient deteriorates and is transferred to ITU
Patient is transferred to HDU
Patient is transferred to ward
Seen by diabetes specialist as OP
Seen by community pharmacist for self care advice
Seen by out of hours service
Seen by cardiology
as OP
Patient notes / communication of information
• Patient / Relative • Vision• A&E record• Inpatient notes (how many types of prescription chart in your board)
• Transfer letter• Community hospital notes• Discharge letter• Temporary set of notes• Community Pharmacist record• OOH records (ADASTRA)• Inpatient/Temporary notes
Medicines Reconciliation to reduce avoidable harm.
• Inadequate medicines reconciliation accounts for up to 20% of adverse drug events and 46% of all
medication errors among hospital inpatients. (Roizic 2001)
• Ensuring that medicines reconciliation is carried out
by a pharmacist (De Winter et al, Clay et al, Gleason et
al)
• Forming strategies to focus on the introduction of an
electronic record (Green et al)
July 2009
October 2008
Failure Modes Effects Analysis (FMEA)
FMEA is a pro-active improvement tool that provides a systematic method of evaluating a process by:
• Identifying where and how it might fail
• Assessing the relative impact of different failures
• Identifying the parts of the process most in need of improvement.
How to carry out an FMEA
Process.
• Be clear what you are looking at.
• Break the process down into steps.
• Be structured and methodical.
• Medicines reconciliation on admission.
• From home as an unscheduled admission.
Definitions.
• Failure Mode – What could go wrong?
• Cause – Why would it go wrong?
• Effects – What would be the consequences of failure?
Step 1.
1.Unable to communicate with patient.
1.1 Patient is unconscious
1.2 Language barrier
1.3 Patient choice or condition
Incomplete information
Possible harm to patient
Use of language line
Local protocol relating to unconscious patient
Group work 2.
• What other failure modes can you think of relating to our process step?
• At your tables think about and document the causes of 1 or 2 failure modes and what the effects would be.
• Time to Score!
1.Unable to communicate with patient.
1.3 Patient choice or condition
1.1 Patient is unconscious
1.2 Language barrier
Incomplete information
Possible harm to patient
Incomplete information
Possible harm to patient
Incomplete information
Possible harm to patient
7
5 1 10 50
7 3 10 210 Ensure a minimum of 2 sources of information are used for medicines reconciliation.
1 10 70
7 x 1 x 10 =
