Upload
annice-day
View
215
Download
1
Tags:
Embed Size (px)
Citation preview
Measuring the value of medication reconciliation – Part 2
Discharge processes at AHS
Tiing Tiing ChihYang Liu
Dr Stephen Lim(Acknowledgement: all senior pharmacists at AHS)
History of Med Rec at AHS
• AHS started admission MR in 2007 as part of WA SQuIRe projects
• “M+M” project – medication matching
• AHS = first hospital to introduce KPIs for Adm Med Rec• % of unintentional discrepancies = 17% Ave 17 unintentional discrepancies for 100 meds
writteni.e. for a patient on 10 medications, 1-2 of the
medications will be an unintentional discrepancy
WHO’s High 5s project from 2010
• Benefits = new measures• MR1
• 50%
• MR2• < 0.1
• MR3 • Canadian benchmark 0.3• AHS:
• MR4• Trending down, last result = 10%
• Event Analysis
Event Analysis
Event analysis beneficial as a “fact finding” tool • investigate patient safety problems
• to identify if there are problems with the SOP• to identify cause and effect
• Multidisciplinary approach• Less labour/resource intensive than RCA• Measurable actions & changes to implement to
improve patient safety
It’s discharge time!
• DC med rec started late 2007• Pharmacist involvements:
• Med list, CMI• Dispensing• Counselling• Community liaison
Discharge Process
DC script
Med chart
MMP
Med list
DC Meds
Counselling DC liaison
CMI
Pharmacist reconciliation
Discharge decision made
Medication reconciliation on discharge
Developmedication
list
Communicate D/C summary with
medication list to GP
Proactive model
Pharmacist: Reviews and reconciles :•BPMH (MMP)•Current medication charts •New medicines to start on discharge•PBS prescription•Patient’s Own MedicinesResolves discrepancies
Provide medication list to
patient
Medical officer:•Checks MMP for outstanding issues •Reconciles with medication charts•Signs off NIMC •Writes PBS script for items requiring supply
Add medication list to discharge
summary
Decision to discharge
patient
Patient shows to GP/others
Discharge summaries at AHSPrior to 2009:
•Medipal • Standalone system • “11th hour changes” not communicated
•Discharge summary sheets • Handwritten by dr on pre-printed format • Nil or only new meds listed• ?? GP liaison• ?? Patient copy
Discharge summaries at AHS
• TEDS (The Electronic Discharge System) implemented in 2009
• Pharmacists populate ADR & med list• “Import” function allows direct copying of meds
from most recent completed TEDS• On completion, GP will automatically be emailed
TEDS medication discharge list example
Current and comprehensive list of medicines •Dose changes, indications, explanations of change•Comments section: can use to provide monitoring advice•Includes stopped medications•Includes Allergies/ADRs
One week DC snapshot
Total discharges surveyed = 61
No active Pcist reconciliation = 22 (36%)
•Nil MMP•Low risk pts
DC reconciliation = 39 (64%)
Pts with discrepancies = 20 (51.3%)
Average discrepancies per pt = 0.72
% incorrect meds per pt = 13%
(i.e. at least 1 error per 10 meds taken)
• PBS & legality check
• Rx to chart matching
• Med list not done by Pcist
Richard’s discharge Admitted for fast AF, CCF secondary to AF, ? Chest
infection Meds on admission:
• Thyroxine 25microg mane• Salbutamol-MDI prn
New meds:• Digoxin 125microg mane (loading 250microg x 2)• Frusemide 40mg mane• Metoprolol 12.5mg bd• Warfarin + enoxaparin tx dose until INR therapeutic• Amoxycillin 500mg tds
Lucy’s discharge
• Admitting diagnosis: NSTEMI• Meds on admission:
• Allopurinol 100mg mane• Methyldopa 250mg bd• Paracetamol-SR 1330mg tds
• New meds started on AMU:• Aspirin 100mg mane• Ticagrelor 180mg loading then 90mg bd• Metoprolol 12.5mg bd
• DC Rx : frusemide & potassium chloride (Dr thought pt was already taking antiplatelets)
Risk factors contributing to DC discrepancies
Multiple med charts Nil MMP in place Brand name confusion Dr not referring to MMP when doing DC script
or summary Dr from different team handling DC
Challenges for DC med rec
Time / FTE Nil MMP in place Dr not contactable to verify discrepancies Late / urgent discharges
Conclusion
AHS measures coincide with High 5s measures MR6
• MR6a (% pts whose DC summaries contain a med list)• MR6b (% pts whose DC summaries contain a current, accurate
and comprehensive list of meds)• MR6c (No. discrepancies per pt)
MR7• MR7a (% pts who receive a med list)• MR7b (% pts who receive a current, accurate and
comprehensive list of meds)• MR7c (No. discrepancies per pt)