High 5s Med Rec (M+R) WHO
project
S Lim, TT Chih, E Fong
Armadale Health Service
WHO High 5s projects
 implement + evaluate standardized
patient safety solutions (SOP)
 Measure to sustain  in patient
safety problems.
 SOP (std op protocol)
 Canada (medication reconciliation)
 UK (concentrated injectables protocol)
 USA (correct site surgery protocol).
 26 Australian hospitals
SOP M+R
 Complete + accurate med list
(BPMH)
 Match this list against the patient’s
admission, transfer, and discharge
orders
 identifying and bringing any
discrepancies to the attention of the
prescriber (changes to orders)
 Any resulting changes in orders are
documented
Measuring M+R:

4 measures (MR1 to MR4)



MR1 process measure
MR2-4 outcome measure
Patient Selection
Patients > 65 y
Admitted inpatient from Emergency Department

Use Independent Reviewer
High 5s M+R measures:
Process Measure
 MR 1: % of Eligible Patients with Medications
Reconciled on Admission within 24 hours
 Important: 2 time points
Outcome Measures (Independent check)
 MR 2: The Mean Number of Undocumented
Intentional Medication Discrepancies Per Patient
 MR 3: The Mean Number of Unintentional Medication
Discrepancies Per Patient
 MR 4: Percent of Patients With at Least One
Unintentional Discrepancy
Flow Chart for Measures
Independent check
Quality Outcome
cf M+M KPIs
Quantity Outcome
Best practice:
Avoid confusion +
Extra work
Documented:
Not collected
cf: M+M KPIs
Collected +
Counted
M+R Baseline July 2010 (AHS)
MR 1
58%
MR2
0.07
MR3
0.4
MR4
30%
AHS MR results July 2010:
 Process Measure:
 MR 1: % of Eligible Patients with M +
R on Admission within 24 hours
 Patients with M+R (<24h) = 155
 Total patients > 65 y adm via ED = 269
 155/269 x 100 = 58%
MR 2: The Mean Number of Undocumented
Intentional Medication Discrepancies Per Patient







“work smart measure”
No. undocumented intentional discrepancies = 2 items
Number of eligible patients in sample = 30
Mean number of Undocumented Intentional Med
Discrepancies per patient = 2/30 = 0.07
Undocumented intentional discrepancies detected was
Prednisolone
Prednisolone 5mg (maintenance dose) BUT dose was written
as 50mg. (intentional)
No documentation why the dose was changed (intentionally).
Time wasted tracking dr when dose is actually correct
MR 3: The Mean Number of Unintentional
Medication Discrepancies Per Patient
 Number of unintentional
discrepancies in sample = 12 items
(detected by independent observer
after MR by pharmacists)
 Number of eligible patients in sample
= 30
 Mean number of Unintentional Med
Discrepancies per patient = 12/30 =
0.4
MR 4: % of Patients With at Least One
Unintentional Discrepancy
 Number of patients with 1 or > 1
unintentional discrepancies = 9
patients
 Number of eligible patients in sample
= 30
 Percent of patients with at least one
Unintentional Discrepancy = 30%
MR and KPIs comparison
KPI1
KPI2
KPI3
KPI4
1 ADE per 200
doses
4 ADEs per
100 unrec
meds.
0.3 M+R
related
intervention
per patient
0.8 ADE per
patient
MR 1
58%
(reconcile)
MR2
0.07
(undoc inten
dis/patient)
0.4
(Unint
dis/patient)
30%
(% patient
with 1 unint
dis)
MR3
MR4
KPI1 : ADEs/1000 doses
Month av = 4.7 ADEs per 1000 doses
= 1 actual ADE per 200 doses
KPI2 % of unintentional discrepancies.
Month av = 17%
= 17 unintentional discrepancies
for every 100 meds written
25
% med discrepancies
% actual ADEs
Percentage
20
15
10
Month av = 4% = 4 actual ADEs
for every 100 meds written.
5
0
May09
Jun- Jul-09 Aug09
09
Sep09
Oct09
Nov09
Dec09
Jan10
Feb10
Mar10
KPI3 Pharmacy Interventions per 100
admissions
Pharmacy interventions per 100 admissions
300
Month av =66 clinical interventions per 100
patients
= 0.7 interventions per patient
Total interventions
250
200
150
Med Rec interventions
Month av = 33 med
rec interventions per
100 patients
= 0.3 med rec
intervention per
patient or 1 M+R
intervention per 3
210
170
140
126
121
116
100
87
73
60
50
40
240
110
108
90
69
58
45
26
35
40
38
45
50% of pharmacist's interventions were med rec interventions
0
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
KPI4 % Unreconciled Med (Actual ADEs) per 100
admissions (M+R > 24h)
160
140
120
Month av = 83 Actual
ADEs per 100 patients
0.8 Actual ADE per patient
100
80
60
40
20
0
May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar09
09
09
09
09
09
09
09
10
10
10