Continuity of Medication Management

Medication Reconciliation: Beyond Admission

HospitalPresenterMonth YYYY

Continuity is an Issue in Health Care

• 10-67% of medication histories contain at least one error1

• Incomplete medication histories at the time of admission have been cited as the cause of at least 27% of prescribing errors in hospital2

• The most common error is the omission of a regularly used medicine3

• Around half of the medication errors that happen in hospital occur on admission or discharge4

• 30% of these errors have the potential to cause harm3,5

NSW Examples - Medication Errors

Aspirin and clopidogrel ceased in ICU and not recommenced when patient transferred to

ward

Patient suffered sudden cardiac

arrest resulting in death

May have contributed to

patient’s death

Patient prescribed ramipril 1.25mg daily, medication chart was rewritten as ramipril

12.5mg daily

Patient suffered pre-syncopal episode, was transferred to HDU and required

noradrenaline

Caused temporary harm and required

intervention

Patient initiated on new cardiac medication,

discharged with no summary or medicine

Patient became acutely unwell and

was re-admitted

Caused temporary harm and required

intervention

Medication Reconciliation

• A process to reduce adverse medication events by:- Ensuring patients receive all intended

medicines- Mitigating common errors of transcription,

omission, commission and duplication - Ensuring accurate, current and comprehensive

medication information follows patients on transfer and discharge

Complete Step 3 and Step 4 at transfers between:- ICU to ward- ED to ward- Ward to ward- Hospital to hospital- Hospital to home or

aged care facilityand

- When re-writing or reviewing medication charts

NSW Medication Management Plan (MMP)Facilitates Medication Reconciliation at Transfers

Area to record medicines taken

prior to presentation

Contains a list of the patient’s pre-admission medications for comparison.

It is available at the point of care.

Know where to find the most accurate list of your patient’s pre-admission medications, commonly referred to as the

Best Possible Medication History (BPMH)

Re-Writing or Reviewing Medication Charts

• Consider re-writing an opportunity to review a patient’s medications:- Pre-admission medications with - Prescribed medications

• Consider:- Medications to be re-started- Medications no longer required- Medications to be adjusted or commenced

• Check:- New chart with previous chart- Any changes made have been documented

Change in Clinical Setting / Ward• Compare:

- Pre-admission medications with - Prescribed medications

• Consider: - Medications to be re-started- Medications no longer required- Medications to be adjusted or commenced

• Communicate:- Medications that are to be continued- Any changes that have been made- Any ongoing plan

ED

ICU Ward 1

Ward 2

Hospital to Hospital• Referring hospital to:

- Communicate- Medications that are to be continued- Any changes that have been made- Any ongoing plan

- Provide a copy of - Pre-admission medications (to facilitate identification

of changes)- Prescribed medications (as a reference for the new

treating team)

Hospital to Hospital

• Accepting hospital to:- Compare

- Medications that are to be continued with previously prescribed medications and pre-admission medications

- Identify and clarify- Any changes that have been made- Any ongoing plan

Hospital to Home or Aged Care FacilityMMP

Medication Chart

Compare:

- Pre-admission medications with

- Prescribed medications

Consider:

- Pre-admission medications to be re-started

- Prescribed medications no longer required

- Medications to be adjusted or commenced

Hospital to Home or Aged Care Facility• Communicate to the next care provider and patient:

- Medications that are to be continued- Any changes that have been made- Any ongoing plan

Example of a medication list for the patient

A Final Check

• Ensure the same medicines information is provided on the:- Discharge summary- Discharge order/prescription- Discharge medicine labels- Patient medication list

• Ensure the patient understands the changes that have been made

Key Points• Medication errors and patient harm can be reduced by

reconciling medicines when re-writing medication charts and at transfers between:- ICU and ward- ED to ward- Ward to ward- Hospital to hospital- Hospital to home or aged care facility

• Providing accurate information at transfers/discharge results in safer ongoing care

References1. Lee JY, Leblanc K, Fernandes OA, et al. Medication reconciliation

during internal hospital transfer and impact of computerized prescriber order entry. Ann Pharmacother. 2010;44:1887-1895.

2. Santell JP, Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32:225-229.

3. Elliott RA, Tran T, Taylor SE, et al. Impact of a pharmacist-prepared interim residential care administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study). BMJ Open 2012; 2:e000918.

4. Stowasser DA, Collins DM, Stowasser M. A randomised controlled trial of medication liaison services – patient outcomes. J Pharm Pract Res 2002; 32:133-40.