Jay Ginsberg, MDNetwork 1 MAC Representative
Why Reconcile Medications?Medication reconciliation is an effective
process to reduce errors and harm associated with loss of medication information, as patients transfer among community-based and hospital providers. It may prevent up to 70% of all potential errors and 15% of all adverse drug events.
-Joint Commission (2006)
Definition of Medication ErrorA medication error is any preventable event
that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.
-National Coordinating Council for Medication Error Reporting and
Prevention
A Great American Philosopher
If the world was perfect, it wouldn't be. Yogi Berra
We don’t want to take this view on Medication Reconciliation!
Who Thinks Med Reconciliation is Important?Institute of Medicine (1999) Joint Commission (2006)CMS
has funded projects to evaluate best practices in medication reconciliation
NQFHas sponsored studies of medication
reconciliation
Medication StatisticsMedication Related Problems are implicated in
16.1% of internal medicine ward hospital admissions.Nelson, KM; Talbert, RL. Drug-related hospital
admissions. Pharmacotherapy. 1996;16:701–707 58.9% of admissions could definitely or possibly be
avoided. Nelson, KM; Talbert, RL. Drug-related hospital
admissions. Pharmacotherapy. 1996;16:701–707Once admitted to the internal medicine ward,
greater than 18% of patient deaths can be attributed to one or more drugsEbbesen, J; Buajordet, I; Erikssen, J; Brors, O; Hilberg,
J; Svaar, H; Sandvik, L. Drug-related deaths in a department of internal medicine. Arch Intern Med. 2001;161:2317–2323
Medication StatisticsAdverse drug events contribute to over 100,000
deaths annually Lazarou, J; Pomeranz, BH; Corey, PN. Incidence of
adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200–1205
25% of ambulatory patients report experiencing at least one adverse drug eventGandhi, TK et al. Adverse drug events in ambulatory
care. N Engl J Med. 2003;348:1556–1564 The economic burden of MRP on the healthcare
system is estimated to be in excess of $177 billionErnst, FR; Grizzle, AJ. Drug-related morbidity and
mortality: updating the cost-of-illness model. J Am Pharm Assoc(wash). 2001;41:192–9
Dialysis StatisticsThe average dialysis patient takes 6 to 10 medicines
a day. Curtin RB, Svarstad BL, Keller TH. Hemodialysis patients’
noncompliance with oral medications. ANNA J. 1999;26:307-316. Kaplan B, Mason NA, Shimp LA, Ascione FJ. Chronic
hemodialysis patients, part I: Characterization and drug-related problems. Ann Pharmacother. 1994;28:316-319.
Szeto et. Al. (Clinical nephrology 2006 vol. 66:4, pp. 256-262)On a-verage, each patient required 4.7 ±1.8 type of
medicationsAverage was 10.0 ± 4.9 tablets per day15.0% needed at least 7 types of medication12.4% had to take more than 15 tablets each day
Is This Important to Dialysis Facilities?Informal Survey Conducted by MAC
Is This Important to Dialysis Facilities?
But:PubMed search revealed only one article on medication reconciliation in dialysis patients
Medication reconciliation in hemodialysis patients; Ledger S, Choma GEvaluation of impact of medication reconciliation
and optimization at the time of patient transfer from an in-centre dialysis unit to a satellite dialysis unit
78.8% of patients had at least one unintended medication variance
The majority of unintended variances (56%) were caused by the physician/nurse practitioner omitting an order for medication that the patient was taking.
“In this small study, medication reconciliation was effective at identifying and rectifying medication errors and optimizing pharmacotherapy at the time of transfer from an in-centre hemodialysis to a satellite dialysis unit.”
Health & Safety Survey Project2006 Survey about Safety ConcernsInvitations to participate in an anonymous
survey sent to 3,587 patients drawn from a representative national patient sample
Network #1 implemented the patient selection and coordinated survey mailing and responses
Surveys completed by 1,762 patients
Health & Safety Survey ProjectDialysis Health ProfessionalsInvitations to participate in an anonymous
web-based survey widely distributed by RPA, Networks, Professional Meetings
Web-based Surveys completed by 649 professionals
Patient ResponsePatient Report of Number of Different Daily Medications
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1 to 5 6 to 10 11 to 15 16 to 20 21 or more
Number Different Daily Medications
Per
cen
t P
atie
nt
Res
po
nd
ents
Patient Response
40% patients report that they discuss their meds with their doctor only “sometimes.”
Health & Safety Survey ProjectProfessional Survey: Past 3 months 43% professionals report 1 or more instances
of patient given the wrong medicine or medicine at wrong time
63% report patients fail to receive 1 of their meds at times
37% report that a patient is given wrong dose of a medication at least once
Overall 77% staff indicate a patient had a medication omission or error in past 3 months
What to do?Considering the large number of medications
taken by the average dialysis patient the problem of medication errors is a huge one.
The practice of Medication Reconciliation offers the opportunity to reduce medication errors and thereby improve patient care.
When is an Accurate Medication List Important
“Handoff” from hospital to Chronic UnitPatients’ medications are changed in the
dialysis unitMedications are changed by an outside
physicianIn a disaster
Components of Medication Reconciliation
Collecting an accurate medication historyMaking certain the medications and the
doses are appropriateEducating the Patients about the MedicationsDocumenting each change that is made along
the way
Collecting an accurate medication history
What has been ordered for the patient?What is the patient really taking?
Making certain the medications and the doses are appropriate
Need list of all medicationsNeed accurate information of the patient’s
co- morbidities
Educating the Patients about Medications
A 2007 study confirms that medication knowledge of hemodialysis patients was extremely poor regarding the name, indication and dosage regimen of their medications BS Sathvik, Seema Mangasuli, MG Narahari, KC
Gurudev, G Parthasarathi Indian Journal of Pharmaceutical Sciences 2007 69:2 232-239
Documenting each change that is made along the way
Each “handoff” should include a reconciliation
Provide health care professionals at each visit by the patient with an accurate medication list
Current PracticesMany facilities have computerized medication
listsHow often are they updated?
Patients are asked to list their medicationsHow often are they asked if they understand
why they are asked to take the medications?Patients may bring in their pills
Are they really taking all those pills?
A Great American Philosopher
If you don't know where you are going, you might wind up someplace else. Yogi Berra
Ways Medication Reconciliation Might Be ImprovedExamples of possible changes in process
Standardized process for checking medications in a unit Med checking on a given day each month
Standardized handoff after hospitalization Part of accepting a patient back into the unit might be a
requirement that a copy of the med list be faxedReview of medication changes after each visit to a
provider The facility might send a form with the patient to be filled
out by the physician’s office staff with any medication changes
Ways Medication Reconciliation Might Be ImprovedAccountability
Medication Coordinator in a facilityPrimary nursing with the requirement that
meds be reconciledEducation of patients about medications
Printed materialsWeb sitesContests at a facility about common
medications
Ways Medication Reconciliation Might Be ImprovedSince facilities vary so much, no answer is
appropriate for allFacilities should be encouraged to do Quality
Assessment and Performance Improvement Projects to improve Medication Reconciliation
Medical Advisory Council of the Forum is attempting to develop tools that can be offered to facilities to help them develop QAPI projects
Sample Tool(Developed by Network 11, Modified by MAC)
FACILITY NAME: PROVIDER NUMBER:
DATE COMPLETED: TEAM MEMBERS
CONTACT: Facility
PROBLEM STATEMENT: 1. Medical Director
2. Facility Administrator
GOAL: 3. Clinical Manager
4. Nephrologists
ROOT CAUSE(S): 5. RD
1. 6. SW
2. 7. PCT
3. 8.
BARRIER(S): External
1. 1. Vascular Surgeon
2. 2.
3. 3.
METRIC(S) Preintervention First
Remeasurement Second
Remeasurement Final
Remeasurement COMMENTS
Sample Tool(Developed by Network 11, Modified by MAC)
TASKSRESPONSIBLE TEAM MEMBER
START DATEESTIMATED
COMPLETION DATE
ACTUALCOMPLETION
DATE
COMMENTS(STATUS, OUTCOMES, EVALUATION, ETC.)
1.
2.
3.
4.
5.
COMMENTS:
A Great American Philosopher
In theory there is no difference between theory and practice. In practice there is. Yogi Berra
PitfallsAssumption that because the medications have
been reconciled the patient is really taking them
Changes in formulationsA brand change of a medication might result in
different absorption that reconciliation would not pick up
The medication list is only accurate if The patient understands what she is takingThe person taking the information is
knowledgeable and thorough
Medication Reconciliation Summary1. Medication Reconciliation is important in
providing quality patient care2. In dialysis units Medication Reconciliation is
particularly important due to the complexity of the patients
3. Components of Medication Reconciliation include:
Collecting an accurate medication historyMaking certain the medications and the doses are
appropriateEducating the Patients about the MedicationsDocumenting each change that is made along the
way
Medication Reconciliation Summary
4. There are several approaches to reducing medication errors and each facility should develop processes that best fit
A Great American Philosopher
It gets late early out there.
Yogi Berra