Leslie Ochs PharmD, PhD, MSPH
Assistant Professor
UNE College of Pharmacy
April 27, 2014
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Describe the importance of medication
reconciliation for patient safety
Identify opportunities, barriers and
challenges in performing successful
medication reconciliation
Identify strategies for effective medication
reconciliation
Describe the importance of your role in
effective medication reconciliation
1.
What is the purpose of medication
reconciliation?
a. To ensure sure patient’s medications meet current
treatment guidelines
b. To decrease patient medication costs
c. To reduce medication errors
d. To decrease the number of medications a patient is
currently taking
“The process of comparing a patient's medication orders
to all of the medications that the patient has been
taking. This reconciliation is done to avoid medication
errors such as omissions, duplications, dosing errors, or
drug interactions. It should be done at every transition
of care in which new medications are ordered or existing
orders are rewritten. Transitions in care include changes
in setting, service, practitioner or level of care”
Best suited for inpatient services
TJC - Issue 35, January 25, 2006
“Reconciliation is a process of identifying the
most accurate list of all medications a patient is
taking – including name, dosage, frequency
and route – and using this list to provide correct
medications for patients anywhere within the
health care system.”
Best suited for outpatient services
Institute for Healthcare Improvement – 2007
http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx
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Process of reconciling a patient’s medication
list at transitions of care
Ensures patient’s medications accurate on
admission to a hospital or nursing home, at
inpatient transfers, on D/C and in community
or outpatient setting
Helps to reduce errors
 Omissions, duplications, incorrect doses and DDI
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Improves communication
TJC - Issue 35, January 25, 2006
Joint Commission on Accreditation
of Health Care Organizations
Institute for Healthcare Improvement
2009 - National Patient
Safety Goal 8
 “Reconcile
medications across the
continuum of care”
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 Ambulatory care
 Emergency and urgent
care
 Home care
 Inpatient services
 Long‐term care
100,000 Lives Campaign
Designed to improve
care and avoid mortality
 Medication
reconciliation –
key component
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Pharmacist’s Letter 2010; Course No. 303
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Difficulties in process
 No clear roles or responsibilities
▪ Duplicate in patient’s medical charts
▪ Documentation in different places
▪ May or may not be in agreement
 Difference in collecting information
▪ Consider OTC “to be medications”?
 Patient’s medical condition
2.
What percentage of patients have unintended
discrepancies on admission to healthcare
facilities?
a.
b.
c.
d.
30%
25%
67%
59%
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Adverse Drug Events (ADEs) happen frequently
 5‐40% of hospitalized patients
 12‐17% of patients after discharge
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Transitions increase discrepancies and the risk
for ADEs
 70% of patients on admission have discrepancies
 1/3 of these are potentially harmful ADEs
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Unintended discrepancies
 67% on admission
 11‐59% harmful
Mueller et al. Arch Intern Med 2012;172:1057
Kwan et al. Ann Intern Med 2013;158:397
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Electronic information
Written information
Patient reporting
Team discussion
Nursing handoff
Between MD
• Direct Interaction – Hospital MD & PC MD – 3-20%
• D/C summary at follow-up appt
• 1st – 12-34%
• 4 week – 51-77%
• Impact in care in 25%
Community Pharmacy Information
• Use more than one pharmacy – not complete
• Poor communication between pharmacies
• Insurance for some medication, cash for others
• Get medical information from patient or family
Long Term Care
• MD and pharmacist not on site
• Assisted living may nit have medication review by pharmacist
Snow et al. J Hosp Med 2009;4:364
Hume et al. Pharmacotherapy 2012;32:e326
Discharge Instructions
• Poor instructions between settings
• Community Pharmacist is out of the loop
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Pharmacist not involved in home services
Limit information sharing with home care
b/misinterpret HIPPA
Discharge visits may be overwhelming
Often not one entity that takes responsibility
for coordinating care. Improved with:
 Patient-centered medical home
 Accountable care organizations
Hume et al. Pharmacotherapy 2012;32:e328
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Older
Cognitive impairment
End of life
Low health literacy
More than 5 medications/day
Disabilities
Low income
Homeless
New admission to long-term care
Hume et al. Pharmacotherapy 2012;32:e328
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Evidence to support pharmacist’s involvement
 36% of patients had medication errors on admission –
85% originated from medication list
 Strategies to reduce medication errors at transitions
include pharmacist medication review at D/C
 Medication review and consultation in various settings
▪ Reductions in MD visits, ED visits, hospital days and cost
Schnipper et al. Arch Intern Med 2006;166:565
Doyle E. September 2009
Mueller et al. Arch Intern Med 2012;172:1057
26 studies
 Provider
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 Usual care
 15 Pharmacist
 6 Information technology
 5 Other providers
Comparison
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Discrepancies
 Intentional &
Unintentional
Feature
Studies Showing
Reduction/Improvement
Medication discrepancies
17 of 17
Potential adverse drug events
5 of 6
Adverse drug events
2 of 2
Post discharge health care utilization
2 of 8
2 Randomized Controlled Studies
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Study #1
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Study #2
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178 pts in Boston teaching hospital
Intervention ‐ Med rec, counseling
with RPh, F/U telephone within 5 days
Control - RN discharge counseling,
RPH reviewed meds without formal
med rec
Results
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▪ 1% Intervention group had pADE
▪ 11% Control group had
pADE(p=0.01)
▪ Total ADEs - No difference
Schnipper et al. Arch Intern Med 2006;166:565
Schnipper et al. Arch Intern Med 2009;169:771
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14 teams; 2 teaching hospitals in
Boston
320 pts
Intervention – Web based electronic
med application – “Preadmission
Medication List (PML) Builder” used
to facilitate med rec process
Control – Resident took med history,
RPH check order, MD wrote D/C
orders, RN educated on meds
Results
Intervention
Control
pADEs
170
230
Admission
44
49
Discharge
126
181
Relative Reduction = 0.72
3.
Which of he following are examples of the
most common medication errors
discovered by reconciling medications?
a.
b.
c.
d.
Wrong dose
Wrong patient
Omission of medications
Extra dose
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Most common errors
 Improper dose or quantity
 Omissions
 Prescribing errors
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Less common errors
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Wrong dose
Extra dose
Wrong patient
Mislabeling
Wrong administration technique
Wrong dosage form
TJC - Issue 35, January 25, 2006
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Continuation of a medication when patient
no longer needs
Omission of outpatient medications on
admission into the hospital
Fail to restart a medication at D/C when
medication was temporarily discontinued
during hospital stay
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Verification
 Collection of the medication history
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Clarification
 Ensure that medications and doses are
appropriate
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Reconciliation
 Documentation of changes in the orders
Institute for Healthcare Improvement – 2007
http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx
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Starts prior to the visit
Review list for duplicate therapies
 Beta-blockers, HTN medications
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Remove discontinued therapies
 Old antibiotic prescriptions
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Remind patient to bring in medications or their list
 Prescription bottles best/medication list
Obtain list of medications
actually filled from the
pharmacy or Health Info Net
Ask all patients to provide a current list of
medications, including OTC and herbals
 Review medication with patient
 Reconcile and document patient’s medication list and
EMR medication list
 Check new medications for interactions/conflicts with
updated EMR medication list
 Provide patient with a paper copy of an updated,
reconciled medication list
 Identify who is responsible to resolve discrepancies
and duplications
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Medications on the “home medication list”
 Prescription medications
 Sample medications
 Vitamins
 Nutraceuticals
 Over-the-counter (OTC) drugs
 Respiratory therapy-related medications
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Drug name
Dose
Route
Strength
Frequency
Indication
Last dose
Who is providing the
information
 Who is collecting the
information
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Prescriptions
Over the counter medications and
supplements
Family members and friends
Samples
Internet prescriptions
Prescription assistance programs
4.
Which of the following are TRUE in regards to
information that should be collected about a
patient’s medications?
a.
b.
c.
d.
Only include prescription and OTC products on the
medication list
Only include those medications that the patient takes orally
Herbal and nutritional supplement information is
unimportant because these products do not interact with
other medications
The most comprehensive and accurate list is important for
medication reconciliation (Rx, OTC, Vitamins, Vaccines, etc.)
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Herbals
Nutritional and dietary supplements
Vitamins
OTC medications
Prescription medications
Respiratory therapy medications
 Inhalers and nebulization treatments
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IV solutions and medications
Vaccines
Radioactive medications
Diagnostic and contrast agents
Pharmacist’s Letter 2010; Course No. 303
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Determine who should be aware of the
changes to the medication list
Ensure sharing discontinued medications
Failure to communicate with pharmacies
leaves prescriptions active on patient profiles
that can be filled by patients
Don’t forget to share the updated medication list
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Multiple chronic disease (>3)
Multiple medications (>10)
High risk medications
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Heart medications
Opioids
Immunosuppressants
Blood sugar medications
Medications with Narrow Therapeutic Index
 Anticoagulants
 Psychiatric medications
 Seizure medications
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No standardized process
Difficult to obtain accurate medication
history
Multiple providers involved in patient’s care
MD office is is not aware of patient’s
prescriptions
ASHP-APHA Medication Management in Care Transitions Best Practices 2013
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Understand the importance
Obtaining complete and accurate
information
Engage everyone in the process
 Health care providers, patients and caregivers
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Create an expectation of the patient that
they receive a current medication list
Develop patient responsibility to carry the list
Time to reconcile medications
 Resources need to complete reconciled list
ASHP-APHA Medication Management in Care Transitions Best Practices 2013
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Review the workflow process and see how medication
reconciliation can best be incorporated within the
facility
Clearly define responsibilities
Remind patients to bring medication bottles
List printed at check-in, patient to review while waiting
for their appointment
Quality audits and feedback on performance/program
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Multidisciplinary Team
 Transitions involve many people - must involve a variety of providers
 Providers must communicate and collaborate well ‐ avoid turf issues and silo
approach
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Institutional Support
CQI central to process - helps document positive outcomes
Dynamic Pharmacy Team
 Changing Roles
▪ Reassessment of job responsibility
▪ Support for pharmacist in expanded role
 Pharmacy extenders can be very useful - pharmacy interns, residents,
technicians
 Training for pharmacy team
▪ Reconciliation, prior authorization, documentation, communication, and data
management
▪ Competencies & protocols to ensure high standards
▪ Schools have focused on this in APPEs
ASHP-APHA Medication Management in Care Transitions Best Practices 2013
Mueller et al. Arch Intern Med 2012:1067
Data to Justify Program
 Metrics to show Return
on Investment (ROI)
 Types of metrics
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Readmit
ED visits
Med Rec problems
Disease specific metrics
Patient satisfaction
Always plan goals and
data collection before
program
Share Information Well
 Efficient transfer of
information
 Approaches for
transferring
information:
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EMR
Prior authorization
E-prescribing
Contacting
provider/prescriber
 Billing options
ASHP-APHA Medication Management in Care Transitions Best Practices 2013
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Best possible medication history (BPMH)
 Structured interview to identify all prescribed and
OTC medications AND
 Verify the results with at least 1 other reliable source
of
information
▪
▪
▪
▪
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Medication vials
Patient medication lists
Community pharmacy record
Clinic record
Medication reconciliation
 BPMH AND Correct discrepancies
Kwan et al. Ann Intern Med 2013;158:397
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Make a standard form or guide to help carry out the process
Make sure the approach facilitates getting a complete list of
medications/treatments
 Dose, route, frequency, immunizations, allergies, herbals, etc
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Put med list where it is easy to find
Determine a timeframe for completion
Assign responsible person at all transitions (e.g., admit,
discharge)
Give patient a discharge med list
Suggest patient carry discharge list and update
Start with a small sample to pilot the process
Provide education to all health care providers participating in
medication reconciliation
Give feedback on program to providers
Pharmacist’s Letter 2010; Course No. 303
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Important component of medication reconciliation
 Communication with pharmacy to obtain accurate
medication history on admission
▪ Important to reducing medication errors
 Communication with patients after discharge
▪
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Counsel medications
Remind to stop taking unnecessary pre-admission regimens
Answer questions
Medication record
Update information
Pharmacist’s Letter 2010; Course No. 303
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Educate patients and family members to serve
as advocates
 Patients understand the complexities of the
medication process and the role they play in
medication management
 Allows patients to keep better track of medications
they are taking
 Have patients bring their medications to every
healthcare encounter
 Educate and empower patients to be responsible for
their medication list
Pharmacist’s Letter 2010; Course No. 303
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The Institute for Healthcare Improvement (www.ihi.org)
 Case studies, literature review, resources, frequently asked
questions
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The Massachusetts Coalition for the Prevention of Medical
Errors (www.macoalition.org )
 Safe practices, sample processes, toolkit, reference list
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The Joint Commission (www.jointcommission.org )
 Information on compliance with standards, frequently asked
questions, flow chart
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The American Society of Health‐System Pharmacists
(www.ashp.org)
 “how to guide, reference list, “clearing house information”
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The Agency for Healthcare Research and Quality
(www.ahrq.gov)
 Toolkit
1.
All of the following are outcomes of an effective
medication reconciliation process except:
a.
b.
c.
d.
Promote overall continuity of patient care
Increase in medication errors
Support safe medication use by patients
Encourage providers and health systems to collaborate
2.
The important steps of an effective medication
reconciliation as suggested by the Institute of
Healthcare Improvement (IHI) include:
a.
b.
c.
d.
Verification
Clarification
Reconciliation
All of the above
3.
What information should a community
pharmacist share when contacted by other
healthcare providers to help update a
patient’s medication list?
a.
b.
c.
d.
Drug name, dose, route and strength
Medication frequency
Last refill or date received
Healthcare provider who is collecting medication
information
e. All of the above
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx
Joint Commission on Accreditation of Health Care Organizations Sentinel Event Alert. Using
medication reconciliation to prevent errors. Issue, January 25, 2006.
www.jointcommisson.org/sentinel_event_alert_issue_35_using_medication_reconciliation
(Accessed April 15, 2014).
Improving Patient Safety: medication reconciliation basics. Pharmacist’s Letter 2010; Course
No. 303
Mueller SK, Sponster KC, Kripalani et al. Hospital-based medication reconciliation practices:
systematic review. Arch Intern Med 2012;172:1057
Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient
safety strategy: a systematic review. Ann Intern Med 2013;158:397
Snow V, Beck D, Budnitz et al. Transitions of Care Consensus policy statement. J Hosp Med
2009;4:364
Hume AL, Kirwin JL, Bieber HL et al. Improving care transitions: current practice and future
opportunities for pharmacists. Pharmacotherapy 2012;32:e326
Doyle E. Medication reconciliation done right. September 2009.
www.todayshospitalist.com/index.php?b=articles_read&cnt=871 (Accessed April 15, 2014).
Schnipper JL, Kirwin JL, Cotungo et al. Role of pharmacist counseling in preventing adverse
events after hospitalization. Arch Intern Med 2006;166:565
Schnipper JL, Hamann C, Ndumele CD et al. Effect of an electronic medication reconciliation
application and process redesign on potential adverse drug events. Arch Intern Med
2009;169:771
ASHP-APHA Medication Management in Care Transitions Best Practices 2013