Medication Reconciliation in Continuing Care Getting It Right Together Creating a Culture of Safety September 8, 2008 Dr. Paula Creighton MD, FRCP(C) Geriatric Medicine Specialist Cape Breton District Health Authority
Jan 16, 2016
Medication Reconciliation in Continuing Care
Getting It Right TogetherCreating a Culture of Safety
September 8, 2008
Dr. Paula Creighton MD, FRCP(C)Geriatric Medicine Specialist
Cape Breton District Health Authority
September 2008 Dr. Paula Creighton Page 2
Outline
Understand why Medication Reconciliation
is getting so much attention through:
• Understanding how adverse drug events (ADEs) commonly occur
• Identify practical steps that can reduce the risk of ADEs in practice
• Identify key features of a safer system
September 2008 Dr. Paula Creighton Page 3
September 2008 Dr. Paula Creighton Page 4
September 2008 Dr. Paula Creighton Page 5
Definition Adverse Event
• UNINTENDED act or event during care
• May result in potential harm
• Harm = increase length of stay
= temporary/permanent disability
= death
September 2008 Dr. Paula Creighton Page 6
September 2008 Dr. Paula Creighton Page 7
How ADEs occur?
• Increase range of medicines to treat or prevent disease
• Multiple co-morbid conditions
• Age-related changes physiology
Tsilimingras, Rosen, &. Berlowitz 2003.
Canadian Patient Safety (CPSI) Institute 2006
September 2008 Dr. Paula Creighton Page 8
How ADEs occur?
• Multiple health care practitioners
• Frequent visit to hospital setting (hospitalization, procedures, tests)
• Adherence problems
Tsilimingras, Rosen, &. Berlowitz 2003.
Canadian Patient Safety (CPSI) Institute 2006
September 2008 Dr. Paula Creighton Page 9
How ADEs occur?
• OTC medication use
• Impaired vision, dexterity, literacy
Tsilimingras, Rosen, &. Berlowitz 2003.
Canadian Patient Safety (CPSI) Institute 2006
September 2008 Dr. Paula Creighton Page 10
When ADEs occur?
• Entry and exit points of clinical encounters
Cornish P. et al Arch Intern Med 2005:165; 424-429
September 2008 Dr. Paula Creighton Page 11
• Labels
• Lists
• Verbal (open ended inquiry)
• Someone else has/will complete
Traditional Medication History
September 2008 Dr. Paula Creighton Page 12
Limitations to Traditional Medication History
Discrepancies:
• Unintentional
• Undocumented Intentional
September 2008 Dr. Paula Creighton Page 13
Unintentional Discrepancies
•Over-the-counter medications
•Shared prescriptions
•Labels “as directed”
•Prescription change without script
•Samples
September 2008 Dr. Paula Creighton Page 14
Undocumented Intentional Discrepancies
• What changed and why?
• Convey a clear understanding of desired outcomes to therapy.
• Written communication with patient/family and pharmacist
September 2008 Dr. Paula Creighton Page 15
Get Involved
Now!safer healthcare
September 2008 Dr. Paula Creighton Page 16
Key Features toward a Safer System
Change
September 2008 Dr. Paula Creighton Page 17
Key for a Safer System
•Doing our jobs differently…
…If you always do what you have always done;
You always will get what you always got
September 2008 Dr. Paula Creighton Page 18
Practical steps to reduce risk of ADEs
• “To prescribe according to best evidence from scientific research and to be mindful of the precepts of patient autonomy”
Holland R, Wright D. Medication Review for Older Adults. Geriatrics and Aging March 2006, Vol 9. No.3.
September 2008 Dr. Paula Creighton Page 19
Practical steps to reduce risk of ADEs
• When might it be best to withhold or discontinue medications that are otherwise appropriate on the basis of guidelines?
September 2008 Dr. Paula Creighton Page 20
Practical steps to reduce risk of ADEs
• Consider life expectancy
• Goals of care and quality of life defined by patient/family
• Potential benefit & risk of medications
September 2008 Dr. Paula Creighton Page 21
Practical steps to reduce risk of ADEs
Start low,
Go slow,
Or don’t start at all!
September 2008 Dr. Paula Creighton Page 22
Practical steps to reduce risk of ADEs
Partnering with Patients
“Nothing about me, without me”
(author unknown)
September 2008 Dr. Paula Creighton Page 23
Medication Reconciliation
Partnering with Patients
• patient/family interview
September 2008 Dr. Paula Creighton Page 24
Practical steps to reduce risk of ADEs
• Humans require formal cues/processes to stay on track reliably
• Reliable work processes account for the known imperfections of humans
Adapted from PSO Training Course (IHI) 2004
September 2008 Dr. Paula Creighton Page 25
Medication ReconciliationMEDICATION RECONCILIATION: include on list below Over the counter products, Samples, Shared pills
Drug NameDrug
Strength
When Taken
Indicate if: -New-Change from label-Effects from new and change
Morning Noon Evening Bedtime
1
2
3
4
5
6
September 2008 Dr. Paula Creighton Page 26
Threats for Change toward a Safer System
• Power Gradient
• Fear
• (Mis)-Perception “touchy, feely” initiatives
September 2008 Dr. Paula Creighton Page 27
Key for Change toward a Safer System
Self audit:
• More mirrors and fewer windows
September 2008 Dr. Paula Creighton Page 28
Self Audit
• "One of the major impediments to convincing people of the prevalence and seriousness of cognitive error is the faith they have in their own thinking abilities"
Croskerry, P. The Science of Human Factors in Healthcare, QHN, October 2003
September 2008 Dr. Paula Creighton Page 29
Key for Change toward a Safer System
“ Many little people
Doing many little things
In many little places
Can change the world.”(Chinese Proverb; author unknown)
Susan Sheridan, Chair, Patients for Patient Safety Strand, WHO World Alliance for Patient Safety; Co-Founder, Consumers Advancing Patient Safety, Eagle, Idaho
September 2008 Dr. Paula Creighton Page 30
Get Involved
Now!safer healthcare