Measuring the value of medication
reconciliation – Part 2
Discharge processes at AHS
Tiing Tiing Chih
Yang 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
written
i.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
Discharge decision made
DC
script
Med
chart
MMP
Pharmacist reconciliation
Med
list
CMI
DC
Meds
Counselling
DC
liaison
Medication reconciliation on discharge
Proactive model
Decision to
discharge
patient
Medical officer:
• Checks MMP for
outstanding issues
• Reconciles with
medication charts
•Signs off NIMC
•Writes PBS script for
items requiring supply
Develop
medication list
Pharmacist: Reviews and
reconciles :
•BPMH (MMP)
•Current medication charts
•New medicines to start on
discharge
•PBS prescription
•Patient’s Own Medicines
Resolves discrepancies
Patient shows to
GP/others
Provide medication
list to patient
Add medication list
to discharge
summary
Communicate D/C
summary with
medication list to GP
Discharge summaries at AHS
Prior 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
Discharge summaries audit
• Big improvements since TEDS implementation in 2009
QUM 5.3,5.8, 5.9
Discharge Discrepancies
•
•
•
•
•
Omission
Wrong dose
Wrong drug
Commission
ADR
One week DC snapshot
Total discharges surveyed
= 61
No active Pcist
reconciliation = 22
(36%)
• Nil MMP
• Low risk pts
• PBS & legality
check
• Rx to chart
matching
• Med list not done
by Pcist
DC reconciliation = 39 (64%)
Pts with
discrepancies
= 20 (51.3%)
% incorrect meds per pt
= 13%
(i.e. at least 1 error per
10 meds taken)
Average
discrepancies
per pt = 0.72
Comparison of Adm & DC MR errors
Discharge errors
Admission errors
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
Richard’s DC script
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)