Continuity of Medication Management
Medication ReconciliationA Systematic Process to Reduce Adverse Medication Events
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
Continuity of Medication Management
Continuity of medication management is achieved when a series of medication management cycles, each of which corresponds to an episode of care, is linked so that information is transferred between cycles (APAC 2005)
Medication Management Pathway
Patient
Procure
Quality audit and review
Decision to prescribemedicine
Record medicine order/prescription
Review of medicine order
Issue of medicine
Provision of medicines
information
Distribution & storage of medicine
Administration of medicine
Monitor ofresponse
Transfer ofverified information
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
Medication Reconciliation4 Simple Steps to Improve Patient Safety
1. Collect a comprehensive medication history
2. Confirm the accuracy of the history
3. Compare the history with prescribed medicines
4. Supply accurate medicines information
1. What is a Best Possible Medication History (BPMH)?
• An accurate and complete medication history, or as close as possible
• Uses at least one other source of medicines information to verify
• More comprehensive than a routine primary medication history
1. Collect a BPMH
• Gather an accurate as possible medication history, using a combination of sources of medicines information:- Patient/carer interview when possible
AND/OR - Other sources of medicines information e.g.
community healthcare provider
2. Confirm the Accuracy of the History
• Verify the obtained information- Use a secondary source to confirm the interview
information OR- Use two or more sources of information to obtain
and verify the medication history
• Explore inconsistencies between the different sources
• The collecting and confirming steps may occur in succession or concurrently
Sources of Medicines Information• Sources may include:
- Patient/carer interview (wherever possible)- GP medication list, referral letter, phone call- Patient medication list- Community pharmacy dispensing history - Residential Aged Care Facility (RACF) medication
chart- Patient’s own medications, prescriptions or dose
administration aids- Previous hospital discharge summary
3. Compare the history with prescribed medicines
• Use the BPMH when determining the medications to be prescribed on admission:- Decide and document the plan for each
medicine e.g. to continue, change, withhold or cease
- Check the medicines that have been prescribed follow the plan
- Compare pre-admission and current medications at every transfer of care
4. Supply Accurate Medicines Information
• Between wards, hospitals and at discharge consider:- Are all medicines prescribed still relevant?- Do any pre-admission medicines
withheld/changed need to be recommenced/changed back?
- Are the changes, including reasons clearly documented?
- Is the list complete and clear for your patient, your team and the next care provider?
A Tool to Facilitate Medication ReconciliationNSW Medication Management Plan (MMP)
Prompts for:- Dose- Frequency- Indication- Duration- Recently ceased- Recently changed- Sources of list- Checklist
Area to record medicines taken
prior to presentation
MMP
Medication Chart
Dr’s Plan column enables comparison with the medication chart atadmission
Reconciliation Complete on Admission
Tick reconcile column
once complete
Identifying and Tracking Issues
Area to record:- Identified medication
related problems - Action required - Person responsible- Result of action
Assisting DischargeAs well as containing a list of the patient’s pre-admission medications for comparison at discharge the MMP can:- Capture medication changes
during admission- Capture comments e.g.
medication administration and supply requirements
- Provide a discharge checklist- Identify patients for home
medicines review
The National Safety and Quality Health Service Standards
• 3 criteria linked to medication reconciliation- Criterion 4.6 The clinical workforce taking an accurate
medication history…- Criterion 4.8 The clinical workforce reviewing the
patient’s current medication orders…and reconciling any discrepancies
- Criterion 4.12 Ensuring a current comprehensive list of medicines, and the reason/s for any change, is provided to the receiving clinician and the patient during clinical handovers
National and International • The Australian Safety and Quality Goals for Health Care:
- Recognise continuity of medication management as an area of priority
- Identify care transitions (admission, transfer and discharge) as an area of concern
- Define patient populations that are at an increased risk of adverse medication events
• The World Health Organisation (WHO) names medication reconciliation as one of its ‘High 5’ patient safety solutions
Key Points• A BPMH results in safer prescribing
• Documenting a BPMH and plan- Improves communication between the health care team- Reduces error, confusion and re-work- Reduces time and error at discharge
• Reconciling at admission, ward/hospital transfer and discharge reduces medication errors and patient harm
• Providing accurate information at transfer/discharge results in safe ongoing care
References1. Tam V, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE.
Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173:510-5.
2. Dobrzanski S, Hammond I, Khan G, Holdsworth H. The nature of hospital prescribing errors. Br J Clin Govern 2002;7:187-93.
3. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424-9.
4. Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual 2005;20:95-8.
5. Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006;15:122-6.