Jay Ginsberg, MD Network 1 MAC Representative. Why Reconcile Medications? Medication reconciliation is an effective process to reduce errors and harm.

Jay Ginsberg, MDNetwork 1 MAC Representative

Why Reconcile Medications?Medication reconciliation is an effective

process to reduce errors and harm associated with loss of medication information, as patients transfer among community-based and hospital providers. It may prevent up to 70% of all potential errors and 15% of all adverse drug events.

-Joint Commission (2006)

Definition of Medication ErrorA medication error is any preventable event

that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.

-National Coordinating Council for Medication Error Reporting and

Prevention

A Great American Philosopher

If the world was perfect, it wouldn't be. Yogi Berra

We don’t want to take this view on Medication Reconciliation!

Who Thinks Med Reconciliation is Important?Institute of Medicine (1999) Joint Commission (2006)CMS

has funded projects to evaluate best practices in medication reconciliation

NQFHas sponsored studies of medication

reconciliation

Medication StatisticsMedication Related Problems are implicated in

16.1% of internal medicine ward hospital admissions.Nelson, KM; Talbert, RL. Drug-related hospital

admissions. Pharmacotherapy. 1996;16:701–707 58.9% of admissions could definitely or possibly be

avoided. Nelson, KM; Talbert, RL. Drug-related hospital

admissions. Pharmacotherapy. 1996;16:701–707Once admitted to the internal medicine ward,

greater than 18% of patient deaths can be attributed to one or more drugsEbbesen, J; Buajordet, I; Erikssen, J; Brors, O; Hilberg,

J; Svaar, H; Sandvik, L. Drug-related deaths in a department of internal medicine. Arch Intern Med. 2001;161:2317–2323

Medication StatisticsAdverse drug events contribute to over 100,000

deaths annually Lazarou, J; Pomeranz, BH; Corey, PN. Incidence of

adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200–1205

25% of ambulatory patients report experiencing at least one adverse drug eventGandhi, TK et al. Adverse drug events in ambulatory

care. N Engl J Med. 2003;348:1556–1564 The economic burden of MRP on the healthcare

system is estimated to be in excess of $177 billionErnst, FR; Grizzle, AJ. Drug-related morbidity and

mortality: updating the cost-of-illness model. J Am Pharm Assoc(wash). 2001;41:192–9

Dialysis StatisticsThe average dialysis patient takes 6 to 10 medicines

a day. Curtin RB, Svarstad BL, Keller TH. Hemodialysis patients’

noncompliance with oral medications. ANNA J. 1999;26:307-316. Kaplan B, Mason NA, Shimp LA, Ascione FJ. Chronic

hemodialysis patients, part I: Characterization and drug-related problems. Ann Pharmacother. 1994;28:316-319.

Szeto et. Al. (Clinical nephrology 2006 vol. 66:4, pp. 256-262)On a-verage, each patient required 4.7 ±1.8 type of

medicationsAverage was 10.0 ± 4.9 tablets per day15.0% needed at least 7 types of medication12.4% had to take more than 15 tablets each day

Is This Important to Dialysis Facilities?Informal Survey Conducted by MAC

Is This Important to Dialysis Facilities?

But:PubMed search revealed only one article on medication reconciliation in dialysis patients

Medication reconciliation in hemodialysis patients; Ledger S, Choma GEvaluation of impact of medication reconciliation

and optimization at the time of patient transfer from an in-centre dialysis unit to a satellite dialysis unit

78.8% of patients had at least one unintended medication variance

The majority of unintended variances (56%) were caused by the physician/nurse practitioner omitting an order for medication that the patient was taking.

“In this small study, medication reconciliation was effective at identifying and rectifying medication errors and optimizing pharmacotherapy at the time of transfer from an in-centre hemodialysis to a satellite dialysis unit.”

Health & Safety Survey Project2006 Survey about Safety ConcernsInvitations to participate in an anonymous

survey sent to 3,587 patients drawn from a representative national patient sample

Network #1 implemented the patient selection and coordinated survey mailing and responses

Surveys completed by 1,762 patients

Health & Safety Survey ProjectDialysis Health ProfessionalsInvitations to participate in an anonymous

web-based survey widely distributed by RPA, Networks, Professional Meetings

Web-based Surveys completed by 649 professionals

Patient ResponsePatient Report of Number of Different Daily Medications

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1 to 5 6 to 10 11 to 15 16 to 20 21 or more

Number Different Daily Medications

Per

cen

t P

atie

nt

Res

po

nd

ents

Patient Response

40% patients report that they discuss their meds with their doctor only “sometimes.”

Health & Safety Survey ProjectProfessional Survey: Past 3 months 43% professionals report 1 or more instances

of patient given the wrong medicine or medicine at wrong time

63% report patients fail to receive 1 of their meds at times

37% report that a patient is given wrong dose of a medication at least once

Overall 77% staff indicate a patient had a medication omission or error in past 3 months

What to do?Considering the large number of medications

taken by the average dialysis patient the problem of medication errors is a huge one.

The practice of Medication Reconciliation offers the opportunity to reduce medication errors and thereby improve patient care.

When is an Accurate Medication List Important

“Handoff” from hospital to Chronic UnitPatients’ medications are changed in the

dialysis unitMedications are changed by an outside

physicianIn a disaster

Components of Medication Reconciliation

Collecting an accurate medication historyMaking certain the medications and the

doses are appropriateEducating the Patients about the MedicationsDocumenting each change that is made along

the way

Collecting an accurate medication history

What has been ordered for the patient?What is the patient really taking?

Making certain the medications and the doses are appropriate

Need list of all medicationsNeed accurate information of the patient’s

co- morbidities

Educating the Patients about Medications

A 2007 study confirms that medication knowledge of hemodialysis patients was extremely poor regarding the name, indication and dosage regimen of their medications BS Sathvik, Seema Mangasuli, MG Narahari, KC

Gurudev, G Parthasarathi Indian Journal of Pharmaceutical Sciences 2007 69:2 232-239

Documenting each change that is made along the way

Each “handoff” should include a reconciliation

Provide health care professionals at each visit by the patient with an accurate medication list

Current PracticesMany facilities have computerized medication

listsHow often are they updated?

Patients are asked to list their medicationsHow often are they asked if they understand

why they are asked to take the medications?Patients may bring in their pills

Are they really taking all those pills?

A Great American Philosopher

If you don't know where you are going, you might wind up someplace else. Yogi Berra

Ways Medication Reconciliation Might Be ImprovedExamples of possible changes in process

Standardized process for checking medications in a unit Med checking on a given day each month

Standardized handoff after hospitalization Part of accepting a patient back into the unit might be a

requirement that a copy of the med list be faxedReview of medication changes after each visit to a

provider The facility might send a form with the patient to be filled

out by the physician’s office staff with any medication changes

Ways Medication Reconciliation Might Be ImprovedAccountability

Medication Coordinator in a facilityPrimary nursing with the requirement that

meds be reconciledEducation of patients about medications

Printed materialsWeb sitesContests at a facility about common

medications

Ways Medication Reconciliation Might Be ImprovedSince facilities vary so much, no answer is

appropriate for allFacilities should be encouraged to do Quality

Assessment and Performance Improvement Projects to improve Medication Reconciliation

Medical Advisory Council of the Forum is attempting to develop tools that can be offered to facilities to help them develop QAPI projects

Sample Tool(Developed by Network 11, Modified by MAC)

FACILITY NAME: PROVIDER NUMBER:

DATE COMPLETED: TEAM MEMBERS

CONTACT: Facility

PROBLEM STATEMENT: 1. Medical Director

2. Facility Administrator

GOAL: 3. Clinical Manager

4. Nephrologists

ROOT CAUSE(S): 5. RD

1. 6. SW

2. 7. PCT

3. 8.

BARRIER(S): External

1. 1. Vascular Surgeon

2. 2.

3. 3.

METRIC(S) Preintervention First

Remeasurement Second

Remeasurement Final

Remeasurement COMMENTS

Sample Tool(Developed by Network 11, Modified by MAC)

TASKSRESPONSIBLE TEAM MEMBER

START DATEESTIMATED

COMPLETION DATE

ACTUALCOMPLETION

DATE

COMMENTS(STATUS, OUTCOMES, EVALUATION, ETC.)

1.

2.      

3.            

4.                              

5.                                   

COMMENTS:

A Great American Philosopher

In theory there is no difference between theory and practice. In practice there is. Yogi Berra

PitfallsAssumption that because the medications have

been reconciled the patient is really taking them

Changes in formulationsA brand change of a medication might result in

different absorption that reconciliation would not pick up

The medication list is only accurate if The patient understands what she is takingThe person taking the information is

knowledgeable and thorough

Medication Reconciliation Summary1. Medication Reconciliation is important in

providing quality patient care2. In dialysis units Medication Reconciliation is

particularly important due to the complexity of the patients

3. Components of Medication Reconciliation include:

Collecting an accurate medication historyMaking certain the medications and the doses are

appropriateEducating the Patients about the MedicationsDocumenting each change that is made along the

way

Medication Reconciliation Summary

4. There are several approaches to reducing medication errors and each facility should develop processes that best fit

A Great American Philosopher

It gets late early out there.

Yogi Berra