Better Medication History Taking: The Way to Improve Medication Reconciliation Ed Tessier, Pharm.D., M.P.H., B.C.P.S. 1, 2 Elizabeth A. Henneman, Ph.D.,
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Better Medication History Taking: The Way to Improve Medication Reconciliation
Ed Tessier, Pharm.D., M.P.H., B.C.P.S.1, 2
Elizabeth A. Henneman, Ph.D., R.N.2, 3
Mark Heelon, Pharm.D.3
Karen Plotkin, Ph.D., R.N.2, 3
Brian Nathanson, Ph.D.4
Supported by a grant from the American Society of Health-System Pharmacists Foundation
1 Baystate Franklin Medical Center, Greenfield, MA2 University of Massachusetts Amherst School of Nursing
3 Baystate Medical Center, Springfield, MA4 OptiStatim, LLC, Longmeadow, MA
Learning Objectives• Discuss the effect of a collaborative nurse-pharmacist intervention on obtaining accurate
medication and allergy histories.
• Identify drug categories frequently missed when obtaining a medication history.
• Identify factors which can improve the effectiveness of medication history taking by nurses.
Outline• The Problem
– Medication History Taking Inadequate.
• What We Did
– Developed tool for nurses to improve medication history taking.
– Trialed tool in controlled environment.
– Trialed tool in clinical setting.
• What We Learned
Medication Reconciliation – The Lived Experience
Medication Reconciliation
process is highly
dependent on obtaining an
accurate medication
history
Adapted from: Tam VC. Knowles SR. Cornish PL. Fine N. Marchesano R. Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Canadian Medical Association Journal. 173(5):510-5, 2005 Aug 30.
Extent of Inaccurate Medication Histories
Systematic Review of 22 Studies involving 3375 Patients% of Patients with One or More Errors in Medication History
0102030405060708090
100
> 1 error Rx > 1 error all Meds
Our Charge
Primary Study Objective
Evaluate the effectiveness of a collaborative nurse-pharmacist
intervention in decreasing medication errors in both
academic and acute care settings.
Study Sites
• University of Massachusetts Amherst School of Nursing– Undergraduate and Graduate Programs
• Baystate Medical Center, Springfield MA– 653-bed academic teaching
hospital
• Baystate Franklin Medical Center, Greenfield MA– 93-bed acute care community
hospital.
Nurse-Pharmacist Intervention Requirements
• Nurse Friendly
• Ability to Integrate into Nursing
Practice
• Resource Neutral
• Transferable Across Settings
• Ability to Integrate in Nursing
Education
What We Did
Tool Developme
nt• Peer
Reviewed by
Nurses and
Pharmacists
Medication History Taking Template Version 3.0
1. GET THE BASICS: • Demographics - First/last name, date of birth • Allergies – Drugs/foods; nature of reaction• Diagnoses - Reason for admit/visit; other diagnoses • Prescribers – Primary and Specialists
2. BUILD THE LISTDo you have your meds/list of meds
with you?
2A. LIST REVIEW• Last updated?• What other medications do you take?
2B. SYSTEM REVIEW•Do you take any medicines for:
•Neuro: Seizures? Headache?•Psych: Sadness? Anxiety? Sleep?•EENT: Allergies? Your Eyes?•Pulm: Breathing? Inhalers?•CV: Your Heart? Blood Pressure?•Endo: Diabetes? Thyroid?•GI: Your Stomach? Bowels?•GU: Contraception? Your Bladder? Treatments for Erectile Dysfunction?•Skel/Musc: Your Bones? Joints?•Infection: Antibiotics?•Derm: Topicals?•Analgesics? Pain or Discomfort?
3. WHAT’S MISSING?• Antibiotics: treatments for HIV, TB? Other infections?
• Cardiac Drugs: antidysrhythmics, antihypertensives, cholesterol lowering?
• Clots: anything to prevent clots? warfarin(Coumadin®), enoxaparin (Lovanox®), aspirin, clopidogrel (Plavix®)?
• Corticosteroids: prednisone, hydrocortisone?
• Diabetes Drugs: insulin? oral agents?
• Electrolytes: potassium, calcium supplements
• Immunosuppressant Drugs: to prevent organ rejection or treat MS, arthritis, psoriasis, Crohn’s?
• Less Than Daily: drugs given irregularly (patches, injections at MD office)?
• MAOI’s: monoamine oxidase inhibitors? (Nardil®, Parnate®, linezolid - Zyvox®)
• Natural: herbal/vitamins, over the counter?
• Opioids: morphine (MS Contin®), methadone, fentanyl
(Duragesic®), oxycodone (Percocet®, Oxycontin®)? • Recreational Drugs: any “street drugs”, use drugs recreationally, smoking, alcohol?
• Seizures: drugs to prevent seizures
4. PROBE FOR MORE
•For medications/conditions with
incomplete information consider one or
more of the following:
• Who ordered the medication?
• What dose?
• When did you last take it?
• Where do you get your medications?
• Why do you take it?
• Tell me about missed doses in the past
week.
• What problems do you have with your
medications?
5. FINAL CHECK
Is there anything else you would like
to tell me about your medications
that I have not asked?
6. ADDRESS ASAP:•Allergy Conflicts•Antibiotics: HIV, TB, other•Anticoagulants: heparins, warfarin•Anticonvulsants: phenytoin, carbamazepine
•Antidiabetics: insulin, oral agents•Antidysrhythmics: amiodarone, procainamide
•Corticosteroids: prednisone, dexamethasone
•Duplicate Medications:• orders for lisinopril and enalapril• total acetaminophen dose/24hrs not over 4000mg
•Immunosuppressant/Transplant Drugs:• cyclosporin, mycophenalate
•MAOI’s: Nardil®, Parnate®, Zyvox® •Opioids: morphine, methadone, street drugs
Trial in Controlled Environme
nt• 16 RN students
• 4 trained actors/
faculty played
scripted standardized
roles as mock
patients each with
medication list
Trial in Controlled Environment16 Senior RN Students
Informed ConsentINTERVENTION
7 StudentsCONTROL
9 Students Randomization
Training+Tool
Med HistoryWith Mock
Patient
AssessmentOf AccuracyTraining+Tool
Med HistoryWith Mock
Patient
AssessmentOf Accuracy
Results of Trial in Controlled Environment
% of Medications Accurately Identified
73%
89%
67%73% 74%
100%
81%
95%
73%
87%
Case 1 Case 2 Case 3 Case 4 Overall
Control Tool
* p < 0.01 using a two sample t-test for proportions
*
Trial in Clinical Setting
• The tool and educational plan implemented on 4 nursing units:– 2 at a community hospital– 2 at a large tertiary care
center • Education:
– Unit poster campaign– One on one sessions with nurses– Nurse “Kit”:
•Laminated Tool with Top 100 drugs Brand/Generic on back.
•Slides/Handouts
Outcome # 1: Medication Events METHODS
• Review of all spontaneously reported medication events on each unit for:
• Initial review by clinical pharmacist, secondary independent review by clinical nurse and by second clinical pharmacist.– Subset 1: All events.– Subset 2: All events related to med history taking.– Subset 3: All allergy events related to med history
taking.
Pre-Intervention3 Month Period
Intervention1 Month Period
Post-Intervention3 Month Period
Outcome # 1: Spontaneously Reported
Medication Events
Rates All Spontaneously Reported Medication Events:
• Community Hospital – Lower POST over PRE: p = 0.181
• Large Teaching Hospital – Similar POST over PRE: p = 0.826
Rates Events Related to Med History Taking:
• Community Hospital - Lower POST over PRE: p = 0.204
• Large Teaching Hospital - Similar POST over PRE: p = 1.00
Rates Events Involving Allergies and Med Histories:
• Community Hospital - PRE vs. POST: no documented events
• Large Teaching Hospital - PRE vs. POST: no documented events
All tests were either Chi Square or Fisher's Exact (Fisher's Exact were used when a count was < 3)
Outcome # 2: Medication Discrepancies
PATIENT SELECTION
Pre-Intervention15 Days
Immediately PriorIntervention
Intervention1 Month Period
Post-Intervention
15 Days Immediately
PostIntervention
50 Consecutive Admissions
Randomized to 25 to ensure a greater variety of caregivers
50 Consecutive Admissions
For Each of the Four Intervention Units:
Randomized to 25 to ensure a greater variety of caregivers
Outcome # 2: Medication DiscrepanciesAlignment of Medication Orders at 3
Points of the Electronic Medical Record
ElectronicHistory
AndPhysical
ComputerizedMedication OrdersDuring Admission
ElectronicDischargeSummary
ElementsCollected:
• Medications• Allergies• Date/Time• Clinical Status• MD
• Medications• Allergies• Date/Time
• Medications• Allergies• Date/Time• Clinical Status
Other Elements Collected: • Demographics• Site of Patient Prior to Admission
Categorization of Discrepancies
MINOR DELAY (BEYOND 48HRS)
Time between admission and POE or first dose exceeded 48 hours – likely benign implications (e.g. multivitamin delay )
IMPORTANT DELAY
(BEYOND 48 HRS)
Time between admission and POE or first dose exceeded 48 hours – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid delay)
MINOR OMIT FOR HOSP. STAY
Drug omitted during hospitalization – likely benign implications (e.g. multivitamin omit)
IMPORTANT OMIT FOR HOSPITAL
STAY
Drug omitted during hospitalization – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid omit)
MINOR OMIT IN DISCH. SUMMARY
Drug omitted in discharge summary – likely benign implications (e.g. multivitamin omit)
IMPORTANT OMIT IN DISCHARGE
SUMMARY
Drug omitted in discharge summary – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid omit)
Outcome # 2: Medication Discrepancies
IMPLEMENTATION
ElectronicHistory
AndPhysical
ComputerizedMedication OrdersDuring Admission
ElectronicDischargeSummary
For Small Community Hospital: • All Data Elements Available Electronically
ElectronicHistory
AndPhysical
ComputerizedMedication OrdersDuring Admission
ElectronicDischargeSummary
For Large Academic Teaching Hospital: • H&P Not Available Electronically
.
Outcome # 2: Medication Discrepancies
RESULTS - Community Hospital Demographics of Pre vs. Post Intervention Similar
Gender did not differ:
• PRE Female = 46.2%
• POST Female = 53.9%
• P-value = 0.423Provider PRE POSTHospitalist 35 (71.4%) 33 (66.0%)General Medical (Non- Hospitalist) 8 (16.3%) 8 (16.0%)
Surgeon 5 (10.2%) 9 (18.0%)Obstetric 1 (2.0%) 0 (0%)
Age did not differ:• PRE: Mean(SD) = 68.1
(18.9)
• POST: Mean(SD) = 69.3 (18.4)
• P-value = 0.756Providers did not differ:
Fisher’s Exact P-value = 0.623, 1 missing value in the Pre-Intervention group
Outcome # 2: Medication Discrepancies
RESULTS - Community Hospital Prior Location did
not differ
statistically
• Observation:
– Trend toward
more complex
patients in PRE vs
POST?
Fisher’s Exact: P-value =
0.083
Location
PRE POST
Home37 (74%)
45 (90%)
Nursing Home
9 (18%) 4 (8%)
Group Home
1 (2%) 0 (0%)
Hospital
2 (4%) 0 (0%)
Rest Home
0 (0%) 1 (1%)
Other 1 (2%) 0 (0%)
0
5
10
15
20
25
Pre Total # of Drugs per H & P Post Total # of Drugs per H&P
Pre Total # of Drugs in CIS Post Total # of Drugs in CIS
Pre Total per Discharge Summary Post Total Per Discharge Summary
Similar but Statistically Smaller Post Intervention (p<0.05)
Outcome # 2: Number of Drugs/Patient
RESULTS – Community Hospital
Outcome # 2: Rates of Discrepancies per Patient
PRE Mean (SD)
[No Discrepancies]
POSTMean (SD)
[No Discrepancies]
P-value
MINOR DELAY (BEYOND 48HRS)
0.14 (0.5) [45/50]
0.14 (0.64) [47/50]
0.461
IMPORTANT DELAY (BEYOND 48 HRS)
0.22 (0.62)[43/50]
0.20 (0.57)[43/50]
1.000
MINOR OMIT FOR HOSP. STAY
1.10 (1.25)[20/50]
0.60 (1.25)[35/50]
0.003
IMPORTANT OMIT FOR HOSPITAL STAY
0.63 (1.24)[33/49]
0.58 (1.36)[38/50]
0.339
MINOR OMIT IN DISCH. SUMMARY
0.28 (0.83)[42/50]
0.06 (0.24)[47/50]
0.110
IMPORTANT OMIT IN DISCHARGE SUMMARY
0.43 (0.71)[33/49]
0.18 (0.44)[42/50]
0.053
What the Intervention Did NOT Affect:
• Length of Stay:
• Allergy Discrepancies:
Variable PRE POST P-value
LOS (Days) 4.20 (5.09)
4.02 (2.86)
0.826
Variable PRE POST P-value
Allergy Discrepancy Rate
0.14 (0.35)
0.10 (0.3)
0.541
Top 10 Drug Discrepancies
These drugs represent 54.3% of all observed discrepancies
0 10 20 30
# of Discrepancies
CARDIOVASCULAR: DIURETICS
MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY
CARDIOVASCULAR: BETA ADRENERGIC BLOCKER
BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS
GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION
RESPIRATORY TRACT: BRONCHODILATORS
HORMONES: ANTIDIABETIC AGENTS
CNS:PSYCHOTROPICS:ANTIDEPRESSANTS
GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES
VITAMINS/MINERALS
0 10 20 30
# of Discrepancies
CARDIOVASCULAR: DIURETICS
MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY
CARDIOVASCULAR: BETA ADRENERGIC BLOCKER
BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS
GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION
RESPIRATORY TRACT: BRONCHODILATORS
HORMONES: ANTIDIABETIC AGENTS
CNS:PSYCHOTROPICS:ANTIDEPRESSANTS
GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES
VITAMINS/MINERALS
Goal: No medication discrepancies
% Patients With NO
Discrepancies:
• PRE: 20% (10/50)
• POST: 42% (21/50)
p = 0.027
What We Learned
Lesson 1: Systematic Approach May Help
• Systematic approach for nurses in
conducting medication histories
associated with modest, but
measurable improvement:
– in controlled setting
– in small community hospital setting
Lesson 2: Alignment of Goals and Responsibilities
• Success in controlled and smaller
settings may be related to:
– Motivated nurses who see medication
history taking as important part of their
job.
Lesson 3: Continuing/Ongoing Reinforcement
• Success in controlled and smaller
settings may be related to:
– Strong and positive one-on-one
pharmacist/nurse relationships.
– Process integrated into workflow.
– Ongoing support for nurses.
Lesson 4: Missed Drugs Include Critical Agents
• Among top drugs in discrepancies:
– Antidepressants
– Drugs for Diabetes Mellitis
– Bronchodilators
– Antiplatelets
– Bronchodilators
– GI Cytoprotectants
– Diuretics
Lesson 5: Catching Discrepancy Early May Reduce
Risk at Discharge
• Intervention early was associated with trend
toward fewer omissions at discharge.
Lesson 6: When in Doubt, Laminate It!
• Intrinsic “value” of tool appeared to improve when
tool was:
– Simplified
– Logical
– Visually Appealing
– Provided Useful Information
• (including the top 100 brand/generic list)
– Durable
– Integrated into Workflow
Half of the modern drugs could well
be thrown out of the window, except
that the birds might eat them.
Dr. Martin Henry Fischer
Now it’s your turn!
State of Med Rec in Rural New England• What is your biggest obstacle?
• Who are the key players at your facility?– MD
– Nurse
– Pharmacist
– Pharmacy Tech
– Other
• What works? Any best practice to share?
• What doesn’t work?
• Anything else to share?
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