Measuring the value of
medication reconciliation
Admission to hospital
Tania Watene
SHPA Standards of Practice for Clinical Pharmacy Services 2013
Hospital pharmacy services that support the medicines management pathway.
Starting out
• High 5s project commenced 2010
• Medication reconciliation had already been
in place for many years at MPS
• Thought we were doing very well
• Detecting and fixing many and significant
discrepancies/errors before patient harm
• High 5s was a way of measuring
Eligible patients
• Target group at highest risk of medicinesrelated problem (SHPA criteria)
• Patients 65 years of age and over
• Admitted to inpatient units
• Entering through emergency department
BPMH
• Best Possible Medication History
• Medication Reconciliation obtained by a clinician
• Includes a thorough assessment of all regular
medication use (prescribed and non-prescribed)
• Involves a systematic patient interview
• Verification of information with more than one source
• Complete and accurate information
- drug name, dose, frequency & route
- represents what the patient is currently taking even
though this may be different from what was actually
prescribed
Measures – MR1
• Percentage of eligible patients who have
received formal medication reconciliation
within 24 hours of the decision to admit to
an inpatient unit.
• Denominator is the number of eligible
patients admitted
• Allows teams to gauge their capacity to
reach as many eligible patients as
possible
MR1
• Mater Health Services MR1 (red line)
• Pretty good
Measuring what exactly?
• “Not previously found (or documented) by the medication
reconciliation team”
• Not measuring the difference between an ad hoc
medication history and formal medication reconciliation
• How many discrepancies do we detect by doing medication reconciliation
• Measuring the accuracy of the end-result formal,
structured medication reconciliation
• How accurate are we at detecting and documenting discrepancies?
• Could we be better?
• Decided to collect both (MR0 = Total number of discrepancies
on admission)
• Clinical pharmacy indicator
• No extra work
Measures – MR2
• Mean number of outstanding
undocumented intentional medication
discrepancies per patient
• Measure of the clarity of prescriber
communication and documentation
• Outstanding discrepancies identified by
the independent observer not previously
found (or documented) by the medication
reconciliation team
MR2
• Mater Health Services MR2 (red line)
• Not so flash!
Measures – MR3
• Mean number of outstanding (undocumented)
unintentional medication discrepancies per
patient
• Measure of non-purposeful discrepancies that
include errors of omission, commission and
description
• Can lead to actual adverse drug events
• Outstanding discrepancies identified by the
independent observer not previously found or
documented by the medication
reconciliation team
MR3
• Mater Health Services MR3 (red line)
• Huge improvement!
Measures – MR4
• Percentage of patients with at least one
outstanding unintentional discrepancy
• Patient-focussed measure
• Measure of the magnitude of patients who
experience a discrepancy
MR4
• Mater Health Services MR4 (red line)
• Huge Improvement
What MR0 tells us
• For MR3 we were achieving significant
differences even before we met the MR3 target
of 0.3
• Unintentional errors of omission, commission
and can lead to actual adverse drug events
• “Obvious” problems
• Highest priority in the short term
• Maintained our ability to detect and document
unintentional discrepancies
What MR0 tells us
Blue line = intentional
undocumented discrepancies at
admission
Red line = intentional
undocumented discrepancies after
BPMH & medication reconciliation
Green line = unintentional
discrepancies at admission
Purple line = unintentional
discrepancies after BPMH &
medication reconciliation
What MR0 tells us
BPMH and Medication
Reconciliation makes a
significant difference to accuracy
of information about medication
use at admission to hospital.
Proportionally much bigger
difference between detection,
documentation and follow up of
unintentional discrepancies
(MR0u vs MR3 p=0.000809)
than of intentional discrepancies
(MR0i vs MR2 p=6.04x10-7).
What MR0 tells us
• For MR2 we are not very good at clarifying
(documenting) reasons for intentional changes to
medications
• Everyone else knows what I know?
• Longer term, this can still be the cause of medication
errors if not clarified
• Not so obviously problematic
• Patient or GP revert to pre-hospital medication schedule
• You come into the hospital wearing size 12 grey pants, a
red shirt, blue shoes, and a black belt….You leave the
hospital wearing a red dress, a blue shirt, no belt and a
size 12 grey thong
• Changing back to what’s comfortable?
Changes for MR3 improvement
• Recognising that we weren’t meeting target
• Previously we had no measure or comparison
• Comparing our interpretation of the significance
of CAMs and PRNs with national interpretation
• Considering the culture of minimal
documentation of decision-making process
(intentional vs unintentional)
• Recognising that Pharmacists had inconsistent
documentation about intervention
when discrepancies were detected
Changes for MR3 improvement
• Discussion with pharmacists about the
importance of documentation of
discrepancies
• Ongoing reinforcement of this
• Education of medical interns about BPMH
process at orientation
• Expanded medical intern education a few
months later
• Definite improvement maintained
Case study
• Daniel – 60y.o man presents for day
procedure (not eligible for High 5s)
• Private hospital – minimal information from
VMO or GP
• Patient didn’t bring own medications
• Patient only knows names of medications,
not doses
• Patient asked to give “best guess” of dose
• No second source used
Case study cont.
• Patient complained of palpitations during
procedure – HR 150 bpm
• Admitted to CCU at 1730h
• Surgeon contacted for telephone order for
night/evening medications
• Medications charted by cardiologist from
patient information
• Still only one source: patient recall
Case study cont.
• Medications charted:
• Dexamphetamine 10mg po tds - withheld
• Allegron® (nortriptyline) 80mg nocte administered
• Paxam® (clonazepam) 20mg nocte
• Nurse noted only 2mg clonazepam tablets in
safe
• Patient unable to recall dose – might be 20mg,
might be 10mg
• Nurse called VMO – reduce to 10mg
Case study cont.
• Pharmacist conducts BPMH & medication
reconciliation next morning (within 24h)
• Uses more than one source of information
• Community pharmacy & patient’s
psychiatrist
• Dexamphetamine 10mg tds – correct (but may
have contributed to tachycardia)
• Nortriptyline 100mg nocte – vs 80mg
• Clonazepam 0.5mg nocte – vs 20mg prescribed,
10mg administered
Case study cont.
• From cardiac perspective, patient deemed
ok for discharge in the afternoon.
• However
•
•
•
•
Patient very weak on his legs, unsteady
Almost fell multiple times on mobilisation to toilet
Denied feeling dizzy, but drowsy ++
SBP 96, HR 60-80
Case study cont.
• Pharmacist recognised significance of
clonazepam overdose
• Clonazepam 30-40h half-life
• 20x overdose (40x overdose prescribed)
• Unlikely to be safe for discharge by the afternoon
• Pharmacist discussed with NUM and both
contacted cardiologist
• Patient required another night in hospital (first
tachycardia, second drowsiness, unsteadiness)
• Discharged following day
• Multidisciplinary CISA
Conclusion
• Structured medication reconciliation soon
after or at the time of admission
• Regardless of entry point for admission
• Reduces number of unintentional errors
• Reduces potential errors by clarifying
intentional changes
• More effective than ad hoc process
• Still room for improvement documentation