Integrated medication management in a tertiary hospital, short-stay medical ward.
Jenkins BG1, Low M1, Tran Q1, Sanfilippo F1,2.
Department of Pharmacy, Royal Perth Hospital, Perth, Western Australia, 2 School of Population Health, University of WA, Crawley, Western Australia.
Background
In 2006, a A prospective cohort study with intervention was
carried out in the Royal Perth Hospital over a 7-week
period1.
This study found that medication discrepancies occurred
at each transition of care from admission to discharge.
Almost half of all intentional 42 (45.7%) and unintentional
101 (48.3%) discrepancies identified on admission by the
pharmacist were not reconciled in the discharge summary
prepared by the junior medical officer.
• This study confirmed the need to investigate a model of
medication management that could capture medication
errors through reconciliation on admission and discharge.
Method
Results
A Project Resource Team consisting of medical, nursing and
pharmacy stakeholders was created to supervise the project.
TEDS Medication Module
Plan-Do-Study-Act (PDSA) methodology was used making
incremental changes and measuring the impact on medication
reconciliation.
Patient Admission
(Continuum)
Process mapping was
used to identify the
health professional
most suitable for the
task.
Aim
•To determine the optimal pharmacy service model to
support integrated medication management on a 32-bed
short stay medical ward.
Objectives
•Enhance the existing discharge summary software (TEDS)
to become the main medication management tool.
Medication
History &
confirmation
Doctor
Medication
Chart
Pharmacist
•Allocate new duties and redesign work-flows to integrate
with medical and nursing processes.
•Created a ‘clean’ prescription signed by the pharmacist and doctor on the
ward, separate from the medication chart, for the dispensary.
Pharmacy Staffing Model
TEDS
Pre-discharge
check & update
Patient
medication list
Pharmacist
•0.5 FTE Junior Pharmacist
Discharge
Summary
Doctor
•0.5 FTE Pharmacy Technician
LEGEND
Position responsible
TEDS Input
TEDS Output
Medication Reconciliation
Transfer of information to
patient / carer and other
health care providers.
The TEDS software was enhanced from a discharge summary
program for doctors to a medication management tool for doctors
and pharmacists to improve the quality of medication information
and assist the medication reconciliation process.
•Medication reconciliation individual steps and as a 4-step
process
•Medical and Nursing satisfaction survey
Medication Reconciliation Rate
•The 4-step reconciliation process started at 0% in June 2007 to a high of
97% for December 2007, averaging 94.3% from December until March 2008.
Process mapping and SHPA practice standards for pharmacists
and technicians were used to assign duties.
Reconciliation Steps
0.5CP
1 CP
Duty
(Main duty = √*)
Validation/Documentation of patient medication Hx
Clinical
Pharmacist
√
Junior
Pharmacist
√*
√*
Assist in obtaining patient medication hx information
Reconciliation of medications on admission
Data entry of medications into TEDS
√*
√
√
√*
√
Coordination of medication supply
Clinical review
Reconciliation of medications on discharge
Generate discharge prescription from TEDS
Organise PBS or Outpatient clinic prescription
Liaison with community care providers
Provide patient medication list & advice on discharge
Pharmacy
Technician
√*
√*
√*
√
√
√*
1CP
1CP
0.5 Tech
100.0%
Med History
80.0%
Confirmation
60.0%
Admission reconciliation
40.0%
Discharge reconciliation
20.0%
0.0%
Jun- Jul-07 Aug- Sep07
07
07
√
√*
√*
√
Oct07
Nov- Dec07
07
Jan08
Feb08
Mar08
Month
√*
√*
1CP
0.4 JP 0.5 JP 0.5 JP
120.0%
Assist in the discharge process
Outcome measures
•The optimum staffing ratio for this ward with 11 admission and discharges
per day, Monday to Friday 0830-1700hrs was;
•1 FTE Clinical Pharmacist
Discharge
prescription
Pharmacist
& Dr
Ward round (collaborative action plan)
•Introduce in stages, a mix of clinical pharmacist, junior
pharmacist, and pharmacy technician roles/positions.
•Pharmacist access and control of the prescription and patient medication list
print function ensured that medication reconciliation became integrated into
the discharge process.
Collaborative
Pharmacist &
Doctor Action
Plan
Doctor /
Pharmacist
•New fields of data to assist medication reconciliation.
•Two extra outputs, discharge prescription and patient medication list.
Medication
Reconciliation &
Identification of
Therapeutic
Problems
Pharmacist
1. Dias L, Jenkins B, Sanfilippo F et al. How does medication reconciliation on
admission in the emergency department (ED) influence the accuracy of
medications on discharge and the discharge summary? Unpublished data. 2007
In 2007 the WA Department
of Health launched the Safety
and Quality Investment in
Reform (SQUIRE) program.
Funding became available to
implement medication
reconciliation, an important
marker for integrated
medication management.
Doctor /
Pharmacist
See separate Poster for full details : Low et al. Discharge Summary Software
as a Medication Management Tool.
Percentage
1
√
Medication reconciliation results, based on a random sample of ~
30 records/month were graphed and reported.
The Staff Satisfaction Survey was conducted in medical and
nursing staff assigned to the ward.
Staff Survey
See separate Poster for full details: Tran Q et al. Staff Satisfaction with New
Medication Reconciliation Processes on the Short Stay Medical Unit.
•Survey results indicated strong approval by doctors and nurses for the new
model of medication management.
Discussion
•The TEDS software enhancement was pivotal in moving to a pharmacist-led medication management process, improving accuracy in all medication outputs.
•New work flows and task responsibility resulted in an efficient and team-oriented environment.
•The shift of medication-related tasks previously undertaken by doctors and nurses was welcomed.
Conclusion
The optimal pharmacy service model to support integrated medication management on this short stay medical ward was found to be that which utilised a mix of pharmacy staff types in varying proportions,
dedicated software that is used by both doctors and pharmacists collaboratively, and a clear understanding of roles and responsibilities between pharmacy, medical and nursing staff.
Acknowledgements
Hilmi S, Hutchings R, Garton-Smith J, Birkett K, Beer C, Dias L, Witney, S
Royal Perth Hospital
Contact Email: barry.jenkins@health.wa.gov.au