Medication reconciliation:
Public vs. Private - is there
are difference?
Dr Treasure McGuire
19 November 2014
You have already met Daniel
• 60 y.o male presented for day surgery in our
Private hospital
• Not eligible for High 5s
– < 65 y.o.
– Not admitted through the ED to inpatient services
– Intention was a hospital stay of < 24 hrs
• When he needed to be admitted
– Medication Hx - No 2nd source used
• Minimal information from VMO or GP
• Patient didn’t bring own medications
• Only knew names of his medicines
• “Best guess” for doses
Case study cont.
Medications charted by cardiologist
Dexamphetamine 10mg po tds (withheld)
Allegron® (nortriptyline) 80mg nocte
Paxam® (clonazepam) 20mg nocte
• Only one source: patient recall
• Nurse contacted Surgeon for Phone order for evening
meds
• Patient no dose recall (20mg vs10mg)
• VMO – reduced to 10mg
Next morning
Pharmacist conducted BPMH (within 24h)
– Used > one source of Med Hx information
• Community pharmacy & patient’s psychiatrist
Dexamphetamine 10mg tds
Correct (but may have contributed to
tachycardia)
Nortriptyline 100mg nocte NOT 80mg
Unintentional discrepancy
Clonazepam 0.5mg nocte NOT 20mg
prescribed & 10mg administered
Unintentional discrepancy
Outcome
20x overdose (40x overdose prescribed)!
Clinically – dizzy, drowsy, unsteady on feet
Required 2 nights in hospital
Would this misadventure have
occurred:
 Across the road in our public
hospital?
 If a BPMH had been taken?
High 5s Medication Reconciliation project
“Assuring medication accuracy at transitions of care”
 Evidence-based patient safety solution sponsored by WHO
 Lead technical agency - Australian Commission on Safety and
Quality in Health Care (ACSQHC)
 10 participating hospitals over the 4-5 year period
(2010-14)
 Most were public hospitals
 High 5s Standard Operating Protocol (SOP)
 Consistent with Australian practice
 Aligns with APAC Guiding principles to
achieve continuity in medication management.
4 Quality Improvement Measures used to evaluate the
process & impact of implementing the Med Rec SOP
Measure
Definition
Target
100%
MR1
Percent of Patients with Medications Reconciled
within 24 hours of the decision to admit the patient
MR2
Mean Number of Outstanding Undocumented
Intentional Medication Discrepancies per Patient
0 -1
MR3
Mean Number of Outstanding Unintentional
Medication Discrepancies per Patient
≤ 0.3
MR4
Percent of Patients with at Least One Outstanding
Unintentional Discrepancy
<40%
MR0
Mean Number of Medication Discrepancies
(Intentional + Unintentional) per patient, identified
at admission (i.e. prior to BPMH)
-
To use these Measures to answer the question
Public vs Private Med Rec: is there a difference
• Need to understand the variables that underpin
Med Rec in both settings
Australian High 5 Sites
Mater Health Services
South Brisbane
Tertiary hospital with public &
private beds (total approx 1000
beds) consisting of:
•
Mater Adult Hospital (Public)
•
Mater Children’s Hospital
(Public & Private)
•
Mater Mothers’ Hospital
(Public & Private)
•
Mater Private Hospital
Variables impacting on the quality of Med
Rec – Public vs Private
Patient cohort
Medical model
MR
0,1,2,3,4
HP conducting
Med Rec
Pharmacy model
1. Patient cohort
Public vs. Private
• Patient cohort – same High 5s criteria
– However
• More social issues in Public setting
• Potential differences in SES, education levels
• Higher use of CAMs
2. HP conducting BPMH
 In the Private system – HP may receive minimal
information from VMO or GP
 Cost-effective BPMH depends on HPs’
 Medication skill base &
 Willingness to obtain >1 source of Med Hx
 Communication skills
In Daniel’s case,
– Nursing staff recorded 1st Med. Hx – relied on only 1 source (patient
recall)
– Neither Prescriber nor Nurse who administered overdose of
clonazepam were familiar with the usual dose range & did not check an
information source.
3. Medical model
At Mater Private
- General reluctance for nursing & medical staff
involvement in conducting a BPMH:
• In-house survey
– “perceived insufficient time” to invest on this
activity
Nurses
• Medication Hx on admission 2-5 mins
vs BPMH (15-30min up to an hour for
complex patients)
3. Medical model
Private VMOs
– Less time for writing scripts &/or documenting care plan – vs JMO in
Public
– Increased reliance on Phone orders
• Rely on memory when giving ward staff medn orders
– Appreciated Pharmacist BPMH
• Stated couldn’t justify time implications
• Wanted Pharmacists to complete BPMH before they write up chart
(& some would like pharmacists to do that for them too!)
If Daniel was in our public system
•  Pre-admission clinic & BPMH avail during & post surgery
(whether intention is to admit or not)
• Missing for Private Surgical Day Patients
4. Pharmacy model
Pharmacy
Mater Public
Mater Private
Alternate Private
model
Service
Clinical service, with
pharmacist in ward
85% of day*
Clinical service, with
pharmacist in ward
85% of day*
Supply on script or
chart
Location
On site, dispensing
from ward
On site, dispensing
from ward
Remote
Pharmacist
to bed ratio
SHPA guidelines
based
SHPA guidelines
based
Script volume based
PBS
Inpatient LAM
Inpatient &
Formulary
Discharge
Discharge only
Our Pharmacy Model is same for Public and Private:
Inpatient &
Discharge
Ward based clinical service M-F 8am til 4:30pm* and ED in public from 7am til 11am
Sat/ Sun & public holidays.
Central pharmacy until 7:30pm M-F and 5:30pm Sat/Sun
We would still have ‘missed’ Daniel’s first Med Hx!
4. Pharmacy model contd.
Mater
MHS “Public”
MHS Private
Alternate Private
model
Communication
methods (of
discrepancies)
Phone, pager, in
person as
discrepancy found.
Less use of clinical
notes
Depends on
seriousness /level of
urgency. More use of
clinical notes. Phone
for more urgent
Phone, pager
Transfer of Med
Hx (in hospital
to community)
e-PCP transposed
to Med List for
discharge
e-PCP transposed to
Med List for discharge
Variable
Detail of
documentation
Variable – moderate Variable – minimal to
to excellent
excellent
ePCP: Mater’s equivalent of an eMAP
•
•
In use for almost a decade
Electronic, real time data collection & reports
May not be
accessible by
pharmacist
Admissions List
Patient Demographics & Admission Information
‘Drugs on Admission’
Drugs on Admission Summary
Patient-specific tasks
Patient-specific tasks
• Series of automatic tasks which appear for all newly admitted
patients
• BPMH
– Completed within 24 hours of admission.
– NOT completed within 24 hours of admission
– Differs from other documented medication history (Delete if no
difference)
Discharge Drugs - Preparation
Drug Profile – Log of ALL Med-related events Admission to D/C
ePCPs – Electronic Pharmaceutical Care Plans
Advantage
• Comprehensive
Medication profile easily
accessed
• Able to “import” from
meds dispensed & from
prev. admissions
• Series of automatic tasks
appear for all new
admissions
• ID outstanding tasks/
profiles to be signed off
• Once “signed-off” faxed
electronically irrespective
of medical/ nursing DC
summaries
Neutral
• Only completed by
pharmacists
• Only 1 profile can be
generated on DC.
Problem if pt classified
as low risk but nurse/
doctor has started a
med profile.
Disadvantage
• Only pharmacy staff
can view the majority
of content
• VMOs can’t access
completed e- profiles
as yet
• No Authorised Form#
(ie some get filed,
some don’t)
So how did Mater perform on
Medication Reconciliation during
High 5 – Public vs Private?
MR0
Mean
Number of
Medication
Discrepancies
per patient
identified at
admission
Mean Number of Medication Discrepancies (Intentional +
Unintentional) per patient, identified at admission (i.e. prior to
BPMH)
MR1
MR1: Percent of Patients with Medications Reconciled
within 24 hours of the decision to admit the patient
Target = 100%
%
MR2 (Target <1)
MR2: Mean
Number of
Outstanding
Undocumented
Intentional
Medication
Discrepancies
per Patient
Target <1
MR3 (Target = 0.3)
MR3: Mean
Number of
Outstanding
Unintentional
Medication
Discrepancies
per Patient
Target = 0.3
MR4 (Target = < 30%)
MR4: Percent of
Patients with at
Least One
Outstanding
Unintentional
Discrepancy
Target = < 30%
Limitations – High 5s SOP
Focus was on admissions via ED:
 Omitted surgical day care patients admitted with
complications
Lack of initial consensus (or individual hospital
perspective) on the potential for clinical impact from
discrepancies wrt:
– CAMs
– PRN unrelated to episode of care
• Sedatives
• Eye drops (non Rx)
• Topicals e.g. Creams
If unrelated to episode of care
Conclusion
Mater High 5 statistics
 MR1 slightly higher in Public vs Private (% Med Recs within 24 hrs of adm)
 But MR2,3,4 & 0 comparable Public vs Private
Med Rec is a feasible model to improve patient
safety / QUM, with comparable outcomes in a Private
vs Public setting IF 3 CRITERIA SATISFIED:
• Model & staff support BPMH
• Staff take time to access resources for double check
• HP conducting the BPMH in any transition of care has a good
working knowledge of not just medication available but their
dose forms, strengths & usual doses