Medication Reconciliation The content of this presentation is the property of the Joint Commission International Commission on Patient Safety. For reference.

Medication ReconciliationMedication Reconciliation

The content of this presentation is the property of the Joint Commission International Commission on Patient Safety. For reference only. No part

of this presentation is to be republished without permission.

Joint Commission International Center for Patient Safety

PresentersPresentersCarol WagnerExecutive Director,Patient SafetyWSHA

Richard J. Croteau, MDExecutive Director for Patient Safety InitiativesJoint Commission International Commission for Patient Safety

Steven M. Riddle,BS Pharm, BCPSLead Pharmacist,Medication Utilizationand Quality ImprovementHarborview MedicalCenter

Sharon I. Eloranta, MDQualis Health

Joint Commission International Center for Patient Safety

OutlineOutline

• Importance of medication reconciliation for patient safety

• Requirements and survey process

• Key steps and effective strategies

• Best examples from around the country

Joint Commission International Center for Patient Safety

Sentinel Event Experience to DateSentinel Event Experience to Date

464 inpatient suicides455 events of surgery at the wrong site444 operative/post op complications358 events relating to medication errors269 deaths related to delay in treatment189 patient falls138 deaths of patients in restraints121 assault/rape/homicide109 perinatal death/injury 94 transfusion-related events 67 infection-related events 66 deaths following elopement 65 fires 58 anesthesia-related events651 “other”

Of 3548 sentinel events reviewed by the Joint Commission, January 1995 through December 2005:

= 3548 RCAs

Joint Commission International Center for Patient Safety

Sentinel Event AlertSentinel Event Alert1. Potassium chloride

2. Policy issues

3. Policy issues

4. Policy issues

5. Policy issues

6. Wrong site surgery

7. Suicide

8. Restraint deaths

9. Infant abductions

10. Transfusion errors

11. High Alert Medications

12. Op/post-op complications

13. Impact of SE Alert

14. Fatal falls

15. Infusion pumps

16. Proactive risk reduction

17. Home fires (O2 therapy)

18. Kernicterus

19. Look-alike, sound-alike drugs

20. Kreutzfeldt-Jakob disease

21. Medical gas mix-ups

22. Needles & sharps injuries

23. Dangerous abbreviations

24. Wrong-site surgery #2

25. Ventilator-related events

26. Delays in treatment

27. Bed rail deaths & injuries

28. Nosocomial infections

29. Surgical fires

30. Perinatal deaths

31. Anesthesia awareness

32. Kernicterus #2

33. PCA by proxy

34. Intrathecal vincristine

35. Medication reconciliation

36. Wrong route / wrong tube

Joint Commission International Center for Patient Safety

Joint Commission International Center for Patient Safety

National Patient Safety GoalsNational Patient Safety Goals

• Each year, a set of Goals will be identified from topics published in Sentinel Event Alert

• A small number of specific requirements for each of the Goals will be identified for survey the following year

Joint Commission International Center for Patient Safety

National Patient Safety GoalsNational Patient Safety Goals

• The Goals and their requirements will be published by mid-year

• Selection of the Goals and requirements will be guided by a panel of experts: the Sentinel Event Advisory Group

Joint Commission International Center for Patient Safety

The Joint Commission 2006National Patient Safety GoalsThe Joint Commission 2006National Patient Safety Goals1. Patient identification2. Communication among caregivers3. Medication safety4. Wrong-site surgery Universal Protocol5. Infusion pumps6. Clinical alarm systems7. Health care-associated infections8. Medication reconciliation9. Patient falls10.Flu & pneumonia immunization11.Surgical fires12.NPSG implementation by network components13.Patient involvement14.Pressure ulcers

Joint Commission International Center for Patient Safety

The JCAHO 2006National Patient Safety GoalsThe JCAHO 2006National Patient Safety Goals

Goal #8: Accurately and completely reconcile medications across the continuum of care.

Joint Commission International Center for Patient Safety

The JCAHO 2006National Patient Safety GoalsThe JCAHO 2006National Patient Safety Goals

Requirement #8.a.

• Implement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.

Joint Commission International Center for Patient Safety

The JCAHO 2006National Patient Safety GoalsThe JCAHO 2006National Patient Safety Goals

Requirement #8.b.

• A complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

Joint Commission International Center for Patient Safety

Why Is Medication Reconciliation Important?Why Is Medication Reconciliation Important?

• The most frequently occurring type of medical error:– Medication errors

• The most frequently cited category of root causes for serious adverse events:– Ineffective communication

• The most vulnerable parts of a process:– Links between the steps (the “hand-offs”)

• Medication reconciliation addresses all of these

Joint Commission International Center for Patient Safety

“Medications” Include:“Medications” Include:

• Prescription medications

• Sample medications

• Vitamins

• Nutriceuticals

• Over-the-counter drugs

• Vaccines

• Diagnostic and contrast agents

• Radioactive medications

• Respiratory therapy-related medications

• Parenteral nutrition

• Blood derivatives

• Intravenous solutions (plain or with additives)

• Any product designated by the FDA as a drug

Joint Commission International Center for Patient Safety

Steps in the Reconciliation ProcessSteps in the Reconciliation Process

1. Develop a complete and accurate list of the patient’s medications

2. Compare (reconcile) the listed medications with any new orders for medications

– Omission

– Duplication

– Interaction

– Name/dose/route confusion

Joint Commission International Center for Patient Safety

Steps in the Reconciliation ProcessSteps in the Reconciliation Process

3. Update the list as orders change during the episode of care

4. Communicate the updated list to the next provider(s) of care (See PC.15.10—PC.15.30)

Joint Commission International Center for Patient Safety

Joint Commission International Center for Patient Safety

When Should Reconciliation Occur?When Should Reconciliation Occur?

• Whenever the organization …“… refers or transfers a patient to another setting, service, practitioner, or level of care within or outside the organization.”

Joint Commission International Center for Patient Safety

When Should Reconciliation Occur?When Should Reconciliation Occur?

• At a minimum …– Any time the organization requires that

orders be rewritten

– Any time the patient changes service, setting, provider or level of care and new medication orders are written

• For transitions not involving new medications or rewriting of orders, the organization determines whether reconciliation must occur.

Joint Commission International Center for Patient Safety

Where Should Reconciliation Occur?Where Should Reconciliation Occur?

• Goal #8: Accurately and completely reconcile medications across the continuum of care.

• Includes all settings of care and any transitions between them … whenever medications are used.– Inpatient

– Outpatient

– Emergency department

– Imaging services

Joint Commission International Center for Patient Safety

Whose list is it, anyway?Whose list is it, anyway?

Requirement #8.b.

• A complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

Joint Commission International Center for Patient Safety

Whose list is it, anyway?Whose list is it, anyway?

What’s on the list?

• All the medications the patient is to be taking after discharge, including dosage, frequency, and route.

Who gets the list?

• The next provider of care

• The patient

Joint Commission International Center for Patient Safety

Discharge Orders, Instructions, ListsDischarge Orders, Instructions, Lists

Discharge orders:

• Directed to other caregivers (treatments, Rx)

• Blanket orders (“resume all …”) are prohibited

Discharge instructions:

• Directed to the patient (self-care)

• “Resume home meds” is permitted

Joint Commission International Center for Patient Safety

Discharge Orders, Instructions, ListsDischarge Orders, Instructions, Lists

Discharge list of medications:

• Complete list of continuing medications

• This is not an order; previous medications do not need to be reordered

Joint Commission International Center for Patient Safety

For more information:For more information:

The Joint Commission Web Site: www.jcaho.org

Joint Commission International Web Site: www.jcrinc.com

Joint Commission International Center for Patient Safety: www.jcipatientsafety.org

My e-mail address: [email protected]

Questions?Questions?

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