Building Bridges
in Medication Management
Kerry Fitzsimons
Dr Ian Craib
Shelley Wood
Clinical A/Prof Peter Kendall
Jodie McNamara
Richard Wojnar-Horton
Fremantle Hospital & Health Service
Western Australia.
Medication Errors can
occur when
• Determining the medication the patient
is currently taking,
• Transcribing details to the medication
chart,
• Prescribing medications for the patient
during the admission, and
• Communicating changes at discharge
to community practitioners.
Kerry Fitzsimons 2010
Why Change Our
Pharmacy Service ?
• High discrepancy rates between
electronic discharge summary (EDS)
and discharge medications.
• Team pharmacist to be more involved
in discharge process.
• Team pharmacist to input medication
information into discharge summary.
Kerry Fitzsimons 2010
SQuIRe
Medication Reconciliation
Project
Safety and Quality Investments for Reform
(Office of Safety and Quality Dept Health WA)
Kerry Fitzsimons 2010
Aim:
• To evaluate an extended clinical
pharmacy service involving:
• Medication reconciliation on admission,
• Medication reconciliation at discharge (EDS),
• Facilitating seamless transfer of medication
information to GP.
• To gauge whether provision of a
medication profile to patients was
beneficial.
Kerry Fitzsimons 2010
Initial goals
To achieve:
• 100% compliance of Medication
Reconciliation Process
• 100% satisfaction with service
• from Medical Team
• patient and
• GPs
• To assess impact on workload of service and
ascertain feasibility of extension of project.
Kerry Fitzsimons 2010
Method:
Clinical pharmacist assigned to a
designated medical team:
• Obtain accurate medication history
• Document current medications on front of chart
• Reconciliation of medications with medical staff
• Input medication information into the D/C summary
• Provide medication information to patient including:
• MedProf © to patients discharged home
• Medication list to patients discharged back to N/H or hostels
Kerry Fitzsimons 2010
Method: Data Collection
• Audit Tool Designed
• Baseline data collected
• Data collected at monthly intervals
(n=30)
• Assessment using an audit tool
• Active arm (1 year)
• Control arm (4 months)
• Roll-out and continuous quarterly reporting
• Outcome Measures
Kerry Fitzsimons 2010
• Medication discrepancy rates on admission
and at discharge.
• Satisfaction survey to GPs and patients.
Results:
Obtaining a Comprehensive Medication
History on Admission
(Mar 2007 - Feb 2008)
1.
% Level of Compliance
100
80
60
40
Active
20
Control
0
Mar
Apr
May
Jun
Jul
Aug
Sep
Month
Kerry Fitzsimons 2010
Oct
Nov
Dec
Jan
Feb
Results:
1.
Obtaining a Current Medication History
on Admission (Active Group)
March 2007 - Nov 2009
Level of Compliance (%)
100
80
60
40
20
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
2007
Kerry Fitzsimons 2010
2008
2009
Results:
2.
Kerry Fitzsimons 2010
Results:
2.
Confirmation of the Medication History
March 2007 - Nov 2009
Level of Compliance (%)
100
80
60
40
20
0
Jan Feb Mar Apr May Jun
Jul Aug Sep Oct Nov Dec
Month
Kerry Fitzsimons 2010
2007
2008
2009
Results:
3.
Kerry Fitzsimons 2010
Results:
Reconciliation on Admission Documented on NIMC
March 2007 - Nov 2009
3.
Level of Compliance (%)
100
80
60
40
20
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov Dec
Month
2007
Kerry Fitzsimons 2010
2008
2009
Results:
Discrepancies Rates and Percentage of
Discrepancies Corrected CONTROL GROUP
Discrepancy Rates and Percentage of
Discrepancies Corrected ACTIVE GROUP
100
100
80
80
60
60
%
%
40
40
20
20
0
0
Mar Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb
Month
% Patients with Medication Discrepancies
% Discrepancies Rectified
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
Month
% Patients with Medication Discrepancies
% Discrepancies Rectified
Results:
4a.
Kerry Fitzsimons 2010
Results:
4a.
Reconciliation at Discharge
Discharge Summary = Discharge Medications Prescribed
March 2007 - Nov 2009
Level of Compliance (%)
100
80
60
40
20
0
Jan
Feb Mar
Apr May Jun
Month
Kerry Fitzsimons 2010
Jul
Aug Sep Oct
2007
2008
Nov Dec
2009
Results:
4b.
Kerry Fitzsimons 2010
Results:
4b.
Documented Medication Liaison
March 2007 - Nov 2009
Level of Compliance (%)
100
80
60
40
20
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
2006/07
Kerry Fitzsimons 2010
2007/08
2008/09
Patient Satisfaction Questionnaire
Feedback from patients (n=43)
• 79% very satisfied with discharge
medication list and found it helpful,
• 58% had shown their GP,
• only 14% reporting problems with
taking their medication.
Kerry Fitzsimons 2010
GP Satisfaction
• Letter to Fremantle Division GPs
to outline project.
• Poor response
– All were satisfied or very satisfied
• Comments include:
“All patients should receive this service”
• Letters supporting the project from
• GP Aged Care representative and
Kerry Fitzsimons 2010
• Fremantle GP Network
Medical Staff Satisfaction
Consultants to interns – all very happy to
support continuation of service
• No official survey - feedback very positive
• Interns – “makes my job much easier”
• Improved clinician awareness of
• medication histories
• medication discrepancies
Kerry Fitzsimons 2010
• the need for accurate communication at
discharge.
Future of Project
• Funding for service.
• Roll-out project to other medical teams
initially and then to other specialities.
• Highlight need for reduced
Pharmacist : Patient ratios (1:30)
to meet all requirements of
Pharmaceutical Review Process
Kerry Fitzsimons 2008
Conclusion
An extended clinical pharmacy service with
adequate staffing ratios (1:30) improved:
• The medication reconciliation process,
• The accuracy of the medication
information communicated to GPs.
• Empowered patient by providing a
medication list at discharge, and
• Support for continuation of service from
GPs, medical staff and patients.
Kerry Fitzsimons 2010
Bridging the Divide
• Narrowing the community – hospital divide.
• Enhanced alliances between practitioners.
• Facilitating accurate medication histories –
improved communication. (GPs, CPs, ACF)
• Liaising with GP Networks
Clinical pharmacists providing
seamless continuity of care.
Kerry Fitzsimons 2010
Pharmacy Department
Medication
Section of
Fremantle Hospital and Health Service
Alma Street, FREMANTLE 6160
(PO Box 480 FREMANTLE 6959)
Telephone 08 9431 2777
Medication Profile
ALLERGY: AMOXYCILLIN (rash)
11 June, 2008
Name: Mrs S
You have been prescribed the following medication. This information will help you use it safely and effectively.
MedicationName
Atorvastatin
Tablets 40 mg
Other Names
Midday
Evening
Lipitor
Isosorbide
Duride
Electronic
Mononitrate
Imdur
Tablets 60 mg
Monodur
Discharge
Imtrate
Enalapril
Tablets 5 mg
Number to Take
Morning
Renitec
Amprace
Summary
Betaloc
Metoprolol
Tablets 50 mg Lopressor
(EDS)
Metohexal
Bedtime
1
1
1
Minax
Aspirin Tablets
100 mg EC
Astrix
Cartia
Glyceryl
Anginine
Trinitrate Tablets
sublingual
600 microgram
To lower cholesterol
levels in the blood.
For relief from
angina, or to improve
pumping of the heart.
1
1
Purpose for
Medication
1
Dissolve HALF to ONE
tablet under the tongue
when needed for chestpain.
For reducing high blood
pressure, or to improve
pumping of the heart or
to prevent kidney
problems.
For treatment of high
blood pressure, angina
or disturbances of heart
rhythm.
To thin the blood and
prevent heart attack or
stroke
To relieve chest pain
associated with
angina.
Special Instructions
Take at night about half an hour before bedtime. Follow dietary
instructions closely. Keep all doctors appointments. Stomach upset
may occur. Contact your doctor if muscle pains or weakness occur.
Do not crush tablets, but they may be broken in half if required. If
dizziness occurs, do not rise quickly from sitting or lying down.
May cause headache and mild stomach upset. See your doctor if this is a
problem.
Take regularly and don't miss doses. Lie down after a dose if dizziness is
a problem. This should only happen with the first few doses. Avoid
potassium supplements unless advised by your doctor. Space doses away
from antacids. May cause cough, changes in taste, rash or stomach upset.
Contact your doctor if these are troublesome.
Take regularly, with food. Do not suddenly stop taking this
medication. Special caution needed in diabetics and asthmatics.
May affect sexual ability, or cause unpleasant dreaming. See your
doctor if this is a problem.
Swallow whole after food. May irritate stomach ulcers and may
worsen asthma or hayfever in some people. See your doctor if
these are troublesome.
Dissolve tablets under the tongue. Do not swallow. You may
experience flushing, headache or faintness. Alcohol may worsen
headaches. See your doctor if these are troublesome. Read the
information sheet provided for further details.
Medication Profile
Pharmacy Department
Fremantle Hospital and Health Service
Alma Street, FREMANTLE 6160
(PO Box 480 FREMANTLE 6959)
Telephone 08 9431 2777
Medication Profile
ALLERGY: AMOXYCILLIN (rash)
11 June, 2008
Name: Mrs S
You have been prescribed the following medication. This information will help you use it safely and effectively.
MedicationName
Other Names
Atorvastatin
Tablets 40 mg
Lipitor
Isosorbide
Mononitrate
Tablets 60 mg
Duride
Imdur
Monodur
Imtrate
Renitec
Amprace
Enalapril
Tablets 5 mg
Number to Take
Morning
Metoprolol
Tablets 50 mg
Betaloc
Lopressor
Metohexal
Minax
Aspirin Tablets
100 mg EC
Astrix
Cartia
Glyceryl
Trinitrate Tablets
sublingual
600 microgram
Anginine
Midday
Evening
Bedtime
1
To lower cholesterol
levels in the blood.
For relief from
angina, or to improve
pumping of the heart.
1
1
1
Purpose for
Medication
1
1
Dissolve HALF to ONE
tablet under the tongue
when needed for chestpain.
For reducing high blood
pressure, or to improve
pumping of the heart or
to prevent kidney
problems.
For treatment of high
blood pressure, angina
or disturbances of heart
rhythm.
To thin the blood and
prevent heart attack or
stroke
To relieve chest pain
associated with
angina.
Special Instructions
Take at night about half an hour before bedtime. Follow dietary
instructions closely. Keep all doctors appointments. Stomach upset
may occur. Contact your doctor if muscle pains or weakness occur.
Do not crush tablets, but they may be broken in half if required. If
dizziness occurs, do not rise quickly from sitting or lying down.
May cause headache and mild stomach upset. See your doctor if this is a
problem.
Take regularly and don't miss doses. Lie down after a dose if dizziness is
a problem. This should only happen with the first few doses. Avoid
potassium supplements unless advised by your doctor. Space doses away
from antacids. May cause cough, changes in taste, rash or stomach upset.
Contact your doctor if these are troublesome.
Take regularly, with food. Do not suddenly stop taking this
medication. Special caution needed in diabetics and asthmatics.
May affect sexual ability, or cause unpleasant dreaming. See your
doctor if this is a problem.
Swallow whole after food. May irritate stomach ulcers and may
worsen asthma or hayfever in some people. See your doctor if
these are troublesome.
Dissolve tablets under the tongue. Do not swallow. You may
experience flushing, headache or faintness. Alcohol may worsen
headaches. See your doctor if these are troublesome. Read the
information sheet provided for further details.