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.,

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?