Medicines reconciliation NHS Lothian ISMP Canada A few points for - - PowerPoint PPT Presentation

Medicines reconciliation –

NHS Lothian ISMP Canada

A few points for our WebEx today:

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Transitions Omissions

High risk meds

WebEx Series for 2017 / 18

POLLING Question: Which of the following professions best describes you? 1. Patient / Service User 2. Medical 3. Nursing 4. Pharmacy 5. Other (please type in chat box)

SPSP Medicines

Prepared by: Gillian Fulton Clinical Pharmacist Acute & Respiratory Medicine Royal Infirmary Edinburgh, NHS Lothian

Working to Improve Medicines Reconciliation

• n Discharge from Hospital

Why MR on Discharge?

• Pharmacy team spent HOURS every day correcting + + + errors on IDLs.
• Care felt reactive and disorganised, with minimal time to proactively
• ptimise care. Discharges were delayed. There wasn’t much joy at work!
• Baseline data collected in 10 patients per week over 10 weeks showed:

– 72.5% of IDLs contained one or more medication errors – Average of 2.8 errors per IDL.

• Adverse drug events known to occur in 20% patients following hospital

discharge(1) and contribute to avoidable readmissions(2).

1. Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers -getting the medicines right. Royal Pharmaceutical Society, London: 2012 2. Witherington EM et al. Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Qual Saf Health Care 2008;17:71-5

....We were definitely too busy to improve!

Measurement

• Data collected prospectively in a random weekly sample of 10 patient IDLs:

Process Measures: – Allergies – Changes to medicines from admission – Accurate list of medicines (HIS outcome measure) Outcome Measures:

– Full compliance with process measures – (Categorised) error count

• Moving to weekly data collection was vital step to improvement. Ensures data is built into routine

and sensitive to change.

• Attempted to categorise data according to potential risk of harm but

was time consuming to collect and not sensitive enough to change.

By June 2017, we will increase the proportion of patients whom have their medicines accurately reconciled on discharge from Ward 207 (a general medical ward) RIE to > 80%

(Measure includes accurate documentation of allergies, changes and list of medicines on the IDL).

In doing so, we will reduce medicine related errors on the IDL by 75% from baseline.

Aim

10 20 30 40 50 60 70 80 90 100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

% Compliance per 10 IDLs

Study Week Number

Med Rec on Discharge Element Compliance, Ward 207

Accurate List of Medicines Changes documented and correct Allergies documented and correct

UCL LCL

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Study Week Number

P Chart: Proportion of IDLs with Full MR compliance on DC

Percent

PDSA Cycles included:

① ECS filed with Kardex ② Real time feedback ③ Medicines Management Plan

(MMP) implemented

④ Education sessions ⑤ Pharmacy Triage Tool amended ⑥ R/V of TRAK controlled-drug files ⑦ IDL template amended

① ② ③ ④ ⑤ ⑥ ④ ⑦

LCL

5 10 15 20 25 30

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

Study Week Number

C Chart: Total number of MR errors per group of 10 IDLs

Count

PDSA Cycles included:

① ECS filed with Kardex ② Real time feedback ③ Medicines Management Plan

(MMP) implemented

④ Education sessions ⑤ Pharmacy Triage Tool amended ⑥ R/V of TRAK controlled-drug files ⑦ IDL template amended

① ② ③ ④ ④ ⑤ ⑦ ⑥

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 5 10 15 20 25

Changes to medicines not documented or incorrect Drug Missing Wrong formulation/device Wrong/incomplete frequency Drug no longer required CD requirements wrong/missing Duplication Allergies not documented or incorrect Wrong dose Wrong/missing course length

Cumulative % Number

Pareto Chart of Errors on IDL (31/10/16 - 27/11/16) Ward 207

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 5 10 15 20 25

Drug Missing Wrong formulation/device Changes to medicines not documented or incorrect CD requirements wrong/missing Wrong dose Wrong/incomplete frequency Drug no longer required Duplication Allergies not documented or incorrect Wrong/missing course length

Cumulative % Number

Pareto Chart of Errors on IDL (27/3/17 - 23/4/17) Ward 207

Give feedback freely…

• BE POSITIVE (wherever you can)
• ASK FOR HELP…

10 20 30 40 50 60 70 80 90 100 31/… 07/… 14/… 21/… 28/… 04/… 11/… 18/… 25/… 02/… 09/… 16/… 23/… 30/… 06/… 13/… 20/… 27/… 04/… 11/… #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A

Percent compliance Full MR Compliance on Discharge

Ward 209, RIE

Potential improvement in MR on discharge from one orthopaedic ward, RIE as a result

• f regular feedback (and enthusiasm!) alone.

Process Change: Medicine Management Plan (MMP)

Process Change: Amendment of IDL Template

Process Change: Amendment of Pharmacy Triage Tool

Phar:1 Med Rec completed: Y Sources used (min.of 2): ECS/Pods/Pt Outstanding Med Rec issues: NIL Outstanding/ ongoing care issues: ? viral illness/beta blocker side effect; bisoprolol restarted recently- dose now decreased during admission . Digoxin level to be done pm (6 hours post dose) High Risk Medicines: Apixaban (AF) Changes to medication: Bisoprolol decreased to 1.25mg Discharge/Compliance information: Dosette. S.H.C pharmacy. Tel: 453-4782 CP: 2283 contacted O/A Phar:D Med Rec completed: Y Sources used (min.of 2): Pt, ECS Outstanding Med Rec issues: nil Outstanding/ ongoing care issues: Rivaroxaban restarted, Haemoptysis resolved. Ceftriaxone stepped down to PO co-amox. High Risk Medicines: Rivaroxaban Changes to medication: Spironolactone started, to complete 7/7 co-amox on d/c. Discharge/Compliance information: Independent

Successes and Cultural Change

• Initial aims achieved with 87.5% reduction IDL medication errors on pilot ward
• Amended IDL template implemented in AMU and all general medical wards
• Wider MDT engagement with discharge MR compared to admission
• 11 wards collecting discharge data across acute and general medicine, ICU,

respiratory, general surgery, MoE, stroke and orthopaedics.

• 9 wards collecting admission data across, acute and general medicine, ICU, general surgery,
• rthopaedics and women and children’s services.
• Acute Medicine QIT established
• Site wide MR working groups established across 3 acute adult sites, with focus on

shared learning and policy development

• Primary care links established to ensure system wide approach to improvement
• QI project commenced in ICU to improve MR on DC from ICU

Ambitions & Next Steps

• Spread and sustainability of improvement
• Work with teams and eHealth to amend IDL templates in other specialties.
• Ensure medication changes are reliably communicated to patients
• INVOLE PATIENTS and work towards co-design of tools and improvement ideas
• Focus on positive feedback in all areas collecting data
• Work on our ‘marketing’ to make medicines QI more visible within secondary care in a bid

to improve our safety culture

• Collect and share patient stories, use emotional process mapping to capture hearts & minds
• Use QI Life to encourage collaboration, communication and innovation
• KEEP AT IT!

SPSP Medicines

Prepared by: Margaret Colquhoun, R.Ph., B.Sc.Phm, FCSHP Aleksandra Stanimirovic, PhD Virginia Flintoft BN, MSc

Medication Reconciliation – Canadian Experience and Audit Tool

“Safer Healthcare Now” – 2005 - 2016

• Convergence of providers across Canada addressing safety interventions
• MedRec > 500 teams, every province represented,
• Developed MedRec Getting Started Kit including a new conceptual

framework

• 2010 - world-wide adoption of framework and measures
• 2013 - identified a need a created a Quality Audit Tool
• > 100 teams from across Canada reporting data monthly

Canadian MedRec Successes

• < 50 bed hospitals to >1500 Beds
• Small: “Personalize medication reconciliation as a local issue with

baseline data”, “Strong leadership led to reliable processes across all interfaces”

• Long Term Care: Full implementation across 62 LTC homes –

“consistent use of data”

• Large Institutions: Use of Pharmacy technician in taking BPMH’s,

committed CEO, use of technology

Accreditation Canada (Health Standards Organization) Required Organizational Practice

What we Learned: Leader’s Survey & Successful teams

• Same issues across institutions, provinces and countries – difficult to

implement reliably across all interfaces of care

• Visible and committed leadership (establish MedRec as expectation)
• Get baseline data! Ensure well understood measurement and tracking
• Do not underestimate time and resources (including training)
• Models must be tailored to fit institution – clarify expectations
• Not a process of matching lists
• Must be patient involvement & clinician engagement
• Focus on the patient!

• 2005-2012 measuring types of discrepancies – quantity vs quality

measure

• 2012 - across Canada, there were ongoing challenges related to the

effective and reliable completion of MedRec processes.

• Measurement of MedRec processes can help to identify areas of

excellence and areas for improvements

• Audit tool launched in 2013
• Collected data on the quality of MedRec at admission in acute and

long term care

• Completed through chart audit

Quality Audit Tool

=

COLUMN HEADINGS:

• Pt. #
• Admit via
• MedRec performed
• Actual Med use verified by

patient/caregiver

• Each med has drug name,

dosage, strength, route, frequency

• Every med in BPMH

accounted for in admission

• rders
• Documented rationale for

holds, D/C meds

• Discrepancies

communicated, resolved and documented

To calculate a MedRec Quality Score, each “Yes” (or “Unable to Perform”) is assigned 1 point for each of the highlighted columns

Medication Reconciliation – Alberta Experience

Organizational Factors

• Hospitals
• Number of Beds - <50; 50 -70; >70
• Teaching status – Teaching; Non-teaching
• Accreditation Status (Yes) – mandatory for ALL hospitals
• Long-term Care Facility
• Number of Beds - <50; 50 -70; >70
• Accreditation Status (Yes/No)

Fidelity Measure

Quality Audit Bundle Compliance at Admission Elements

1. BPMH > 1 source 2. Actual Med verified by Patient/Caregiver 3. Each med has drug name, dose, strength, route, frequency on BPMH and Admission Orders 4. Every med in BPMH is accounted for in Admission Orders 5. Prescriber has documented rationale for ‘Holds” and “Discontinued” meds

• Used to assess internal validity & account for negative or ambiguous findings

Background – Acute care settings/hospital

• 1. Highest ADE related ED visits - hospital with substantially worse performance in

‘pre’ period (Dedhia et al. 2009)

• 2. (+) impact of Med Rec at admission in a small hospital ED (Vira and colleagues

2006)

• 3. ADE-related readmissions (geriatric ward) 80% post period for patients >=80

(Gillsepie et al. 2009)

• 4. Pharmacist assisted Med Rec ADE related readmissions (10 % in the intrv group

vs 38.1 % in ctrl group, P = .04) (Koehler et al 2009)

• 5. Med Rec at admission alone unlikely to impact the rate of ADEs related events

(Cornish et al. 2005); (Kwan et al. 2007); (Fernandes & Shojania 2012)

Background – Long-term care facilities

1. Protective effect on composite outcome (Crotty et al. 2004) 2. LTC residents likelihood of discrepancy-related ADE (adjusted OR ¼ 0.11, P ¼ .05) post Med Rec (Boockvar et al. 2006) 3. Systematic review of Med Rec - hospital admissions in patients transferred to & from LTC settings (Chhabra et al. 2010)

Cohort description

Implementation of MedRec Audit tool intervention by June 2014:

Designation MRQA Med Rec participating facilities Alberta’s publicly funded healthcare facilities N N

Acute Care Units

52 (83%) 63

Long-Term Care facilities

63 (19%) 335 Total Facilities 115 (29%) 398

Organizational Characteristics

Criteria Categories Acute Care Long-term Care # of Beds <50 28 (67%) 33 (52%) 50 - 70 1 (2%) 11 (18%) >70 13 (25%) 19 (30%) Unknown 10 Teaching Teaching 8

• Non Teaching

34 (75%)

• Accreditation Status

Yes 52 (100%) 56 (89%) No

• 7 (11%)

Results – Fidelity measure

Month Acute Care setting Long-term Care setting

N Fidelity Score N Fidelity Score

M1 (June ‘14) 1190 2.62 64 4.16 M2 (July ‘14) 1323

2.50

54 4.28 M3 (August ‘14) 1129 2.65 37 4.54 M4 (September ’14) 1165 3.08 53

4.57

M5 (October ’14) 1791 2.74 59 4.36 M6 (November ’14) 1043 3.04 36

4.06

M7 (December ’14) 2434 2.80 51 4.51 M8 (January ’15) 1171 2.91 57 4.46 M9 (February ’15) 2114 2.85 54 4.15 M10 (March ’15) 1330

3.19

88 4.52

Results – Acute Care setting

• Organizational factor analysis

– Hospital size may impact the compliance with the elements of the quality audit tool – Larger size hospital (p-value <.0001) and teaching hospitals (p-value = .0047) were likely to experience higher volumes of ADE related hospitalizations and may be related to patient volume

Results – Long-term Care setting

• Organizational factor analysis

– LTC Facility size (p-value <.2371) & accreditation status (p-value .1712) NOT associated with changes in # of ADE related ED visits or ADE related hospitalizations

Possible explanation(s) for differences in findings

• 1. Population being evaluated
• 2. Patient volume and acuity
• 3. Time requirement for completion of MedRec audit

– 24 hours in Acute care vs 14 days LTC

• 4. Implementation diversity
• 5. Med Rec compliance at Acute care admission not directly

related to ADE events

Lessons Learned

• Adhering to Med Rec process takes time
• 5 to 60 mins per admission
• Consistency of application requires a standardized delivery

model

• Effectiveness and Cost effectiveness of Med Rec across the

continuum of care (admission; transfer and discharge) to be considered

Bundle of Patient Centred Care

Conclusion

• Acknowledge existence of ADEs, identify them, and analyse

their causes

• Continuing effort to improve patient safety rather than an

approach that finds and attaches blame to individuals and

• rganizations

Resources: CPSI, ISMP Canada

• Tools, webinars, reports
• National MedRec Strategy
• Paper by CPSI, ISMP Canada, Accreditation Canada
• Paper to Electronic Toolkit

Questions for our presenters

We would love to hear from you to co-create the WebEx series for 2018/19.

Work with us to make 2018/19 a success

See you on 15th March…….

hcis-medicines.spsp@nhs.net http://ihub.scot/spsp/medicines/ @SPSP Medicines