ISMP Canada ismp-canada

© Institute for Safe Medication Practices Canada 2007®© Institute for Safe Medication Practices Canada 2007®

MedsCheck and Hospital Medication Reconciliation

Improving Patient Safety Building the

Community Pharmacy and Hospital Partnership

Ottawa OntarioOct. 14, 2008

Margaret ColquhounProject Leader ISMP Canada


ISMP Canadawww.ismp-canada.orgwww.ismp-canada.org

To identify risks in medication use systems, recommend optimal system safeguards and advance safe medication practices.

Work to advance safe medication use.

http://www.ismp-canada.org/


Agenda 1. Welcome and Introductions

2. Medication reconciliationOverview and progress of work in institutions including discharge medication reconciliation

3. MedsCheck and Medication Reconciliation Pre-surgical MedsCheck for elective surgical patients – who, what, how?

4. Planning TogetherSummary and next stepsStaying in touch


Medication Reconciliation• Formal and consistent process in which most accurate list of patient’s home medications are compared at transitions of care: admission, transfer, discharge, LTC, homecare

• Discrepancies are identified, brought to attention of physician, required changes are made and communicated

• Intended to minimize potential patient harm from unintended discrepancies


Medication Reconciliation

Is also…

• A high priority objective for all hospitals in Ontario• A Required Organizational Practice for

Accreditation Canada• One of the Safer Healthcare Now! Initiatives• A process that will become the new way…not a

project

Schematic of Structured, Multidisciplinary Integrated Schematic of Structured, Multidisciplinary Integrated

Medication Reconciliation StrategyMedication Reconciliation Strategy

Wong J. Annals of Pharmacotherapy 2008 (in press)Wong J. Annals of Pharmacotherapy 2008 (in press)

BPMH medical chart

One history only

Primary Medication

History: MD or RN

Admission Admission ReconciliationReconciliation

ER

WardBPMH:

Taken by pharmacist

11



Published Studies: “Unintended Medication Discrepancies

at the time of Hospital Admission”

• 151 patients• At least 4 regular prescriptions, admitted to GIM teaching hospital

• 53.6% of patients at least 1 unintended discrepancy [95% CI 45.7%-61.6%]

• 46.4% of errors – omitted medication• Patient Impact : 38.6% had the potential to cause moderate to severe discomfort or clinical deterioration

• Cornish P et al. Arch Intern Med 2005:165;424-429


Published Studies: “Patient Medication Adverse Events Post

Discharge”

328 patients who were discharged from a Canadian teaching hospital were studied prospectively in 2002

for 14 weeks. (AJ Forster,et al., CMAJ 2004:170(3)345-349.)

11%16%

72%

Threrapeutic Errors Adverse Drug eventNosocomial Infections

Developed by Courtyard-Group for E-Health Conference 2004

23% of Discharged Patients from a Canadian Hospital experienced an adverse event – of those 72% were drug

related


Published Studies: The Case for Medication Reconciliation

• Many patients (70%) not receiving medication instructions at discharge

(Alibhai SMH, Han RK, Naglie G. Medication Education of Acutely Hospitalized Older Patients. J Gen Intern Med 1999 Oct;14: 610-616)


Stories from Medication Reconciliation Teams: Medication

reconciliation Failures

•Transplant rejection drugs not ordered on admission (>48hr delay in restarting)

•Glaucoma meds missed for 14 days


Med Rec Admission Failure

• LB was admitted to a medical ward with a working diagnosis of community acquired pneumonia

• Appropriate antibiotics & symptom management ordered & commenced

• 2 days later LB suffered a myocardial infarction (HR 168)

• Beta-blocker was not continued on admission


Current Picture

• We do not have seamless communication systems…………and patients know it

• There is duplication of effort in community and hospital

• There is potential for unintended adverse drug events


• Patient Interview

• Labels on Rx Vials

• Medication Lists

• Family MD list

• Patient’s own list

Patient’s Actual Medication Use

• Medical chart

• Medication wallet

cards

• Community pharmacist

Patient’s Prescribed Medication Regimen

What is the “truth”?

Hospital PerspectiveHospital Perspective

What is the patient supposed to be on?What is the patient supposed to be on?


RX’s from the hospital• Missing information (medication

name, dose, frequency, quantities LTD codes)

• Illegible

• Automatic substitutions while in hospital

• Drugs not covered by ODB or drug plan

• Section 8’s not applied for

• Knowing which meds were intentionally discontinued or were they unintentionally missed

Other sources of information:

•Patient profile on the computer (not reflective of recent changes)

•Patient or agent (usually know little)

•Hospital Physician /Nursing station (impossible to acquire info)

What is the patient supposed to be on?

Community Perspective Community Perspective


MedsCheckOntario Ministry of Health and Long-Term Care

• Funded by MOHLTC

• One-on-one 30 minute appointment with the community pharmacist

• Reviews all the patient’s medications (prescribed and OTC)

• Helps patients better understand their medication therapy and ensure that medications are taken as prescribed.


Who is eligible for a MedsCheck?

• All Ontarians are eligible

• Once per year

• No additional cost to client

• Provided they are taking 3 or more medications for a chronic condition.

• Community Pharmacist is reimbursed for their professional services.


MedsCheck Personal Medication Record


What’s a MedsCheck Follow-up?

• MedsCheck Follow-up is a program for patients who may benefit from additional MedsChecks during the annual timeframe.

• There is no limit to the number of Medscheck Follow-ups provided they meet the following criteria:

A planned hospital admission (e.g. elective surgery)

A physician or registered nurse in the extended class (RN[EC]) request

A recent discharge from hospital (within 2 weeks)


Overview of MedsCheck/Medication Reconciliation Pilot

To facilitate the linkage of the MedsCheck program in community pharmacies with the medication reconciliation process in hospitals in communities across Ontario.


Pilot Objectives

To Improve :

• Communication of medication information

• Continuity of care for the patient/client at transitions of care.

• Accuracy of medication ordering • Efficiency by reducing re-work


Linking MedsCheck to MedRec Pilot

ISMP Canada 2008

• 14 hospitals

• Pre-admission surgical clinic - elective patients

• Requesting patients to arrange a MedsCheck 1-2 weeks prior to their pre-admission clinic appointment

• Create the Best Possible Medication History (BPMH) in hospital using MedsCheck as the primary source of information

• Collect data - time to complete BPMH and quality of MedsCheck

Pre-op Appointment

Day ofSurgery

OR

Surgical Unit

Transfer Units (Rehab)

Home

1

12

2

Our Initial Focus: Pre Surgical Admission Reconciliation

• Prevent inadvertent omission of needed home meds

• Prevent errors associated with orders having incorrect doses or dosage forms

1

2

•Prevent failure to restart home meds following discharge and transfer

•Prevent duplicative therapy at discharge (i.e. brand/generic, formulary substitutions)

Pt brings MedsCheck and

vials to pre-op clinic date

Patient gets a MedsCheck 2 weeks

before pre-op clinic date

Surgeon asksPt to get a MedsCheck

BPMH created using MedsCheck plus 1 other

source

Day Surgery nursereviews

medication list with patienton day of surgery

Patients sees community

pharmacist for MedsCheck Follow-up

POST-OPSurgeon reviews and orders meds

using BPMH

Co-ordination Process Flow

Discharge MedRec

UPDATE:

• Booklets

• Pamphlets

• Hip/Knee binders

• Verbal reminders

Hospitals:

• Phone reminders

• Calling/Faxing their pharmacies BPMH is updated


Supports for Hospitals

• Checklists

• Revised sample forms

• Data collection tools pre and post MedsCheck

• Community pharmacists BPMH presentations and meetings such as this one

• Sharing teleconferences

11. Transportation

10. Appointment with your surgeon for postoperative follow-up visit

9. Anticoagulation therapy stop date

8. Staples/clip removal date

7. Discharge date from hospital

6. Community Care Access Centre (CCAC) visit or Outpatient Physiotherapy postoperative appointment

5. MedsCheck appointment with your community pharmacist (if you are on 3 or more prescribed meds)

4. Appointments with specialists

3. Appointment with your family doctor

2. Preoperative assessment

1. Date of surgery

DateAppointment/Activity

My Total Joint Replacement Passport

Please use this passport to record the dates for all of your appointments and other activities. The next page explains each appointment / activity in more detail.

My surgeon is Dr. _________________________. His/her office will contact me with my surgery date.

My family member/friend who will assist me throughout my joint replacement is: _______________________.

He/she can be reached at: _________________.

Bring this passport with you to all appointments.

Sample: My Total Joint Replacement Passport

Used with permission from Markham Stouffville hospital


The forms and applications must be completed before your preoperative visit to the hospital. If you have any questions, it is fine to contact your surgeon’s office for assistance.

These forms must be brought with you to your preoperative assessment visit at the hospital:

• History and Physical Form• Anesthesia Patient Questionnaire• Inpatient Rehabilitation Application• MedsCheck from your community pharmacist if you

are on 3 or more prescribed medications

Sample: Forms and Applications


Translator - If your primary language is not English, please arrange to have a translator with you for all your appointments including on the day of your surgery.

A family member, friend, or caregiver who will be helping you after surgery.

A snack and drink as you will be at the hospital for 4-5 hours; this is particularly important if you have diabetes.

MedsCheck from your community pharmacist if you are on 3 or more prescription medications.

All medications you are taking at home in their original containers with the labels (include prescription eye drops and creams, herbal and over-the-counter medications).

Copies of any recent blood work or diagnostic tests that you have had done outside of Markham Stouffville Hospital.

History and Physical form – completed by your family physician.

The Anesthesia Patient Questionnaire – completed by you.

Rehabilitation Application – completed by you.

The forms given to you with this guide are to be brought in with you to the SAC appointment or returned prior to the appointment. If you have mailed or faxed these forms, you must ensure they reach the hospital before this appointment.

Surgical Assessment Clinic (SAC)

Appointment Checklist

What to Bring with You

Bring this patient guide with you. Your orthopedic team will review your passport with you to ensure

you are completing all of your presurgical preparations correctly.

Sample: Surgical Assessment Clinic (SAC) Checklist

Used with permission from Markham Stouffville hospital


Coordinating MedsCheck and Medication Reconciliation in Ontario will:

Positively impact the entire continuum of patient care:

• Seamless transfer of information • Support patients to take/receive medications correctly and appropriately during transitions in care.

• Reduce the potential for medication errors/adverse drug events

• Improves efficiency and accuracy


Coordinating MedsCheck and Medication Reconciliation in Ontario

will:

• Develop and strengthen the relationship between patients and their community pharmacist.

• Improve patients understanding of their medications by reviewing them in the community and again in hospital at discharge.

• Encourage hospital and community pharmacies to work more closely together to improve communication and patient care.


Hospital Roles

• Change processes to direct patients to book a MedsCheck prior to pre-admission clinic date. • Surgeons, pre-admit nurses, forms and tools

• Pilot hospitals have resources to share E.g Checklist

• Train preadmission staff to ask for a MedsCheck by name when doing BPMH and use it.

• Further implement discharge medication reconciliation


Community PharmacistsRole

• Book MedsCheck for pre-admission clinic patients when they ask or if contacted by the hospital

• Perform MedsCheck• Record all the medications the patient is actually taking. If it differs from the prescribed instructions then document the discrepancy in comments section.

• Include all current prescription and over-the-counter medications. (aspirin, iron, potassium)

• Ask about medications dispensed from other pharmacies.

• Perform Follow-up MedsCheck at Discharge within 2 weeks


Innovations we’ve heard about - hospitals

• Using SPEP students to follow patient from SAC visit to admission

• Using volunteers to phone patients to remind them to get a MedsCheck

• Phoning/faxing pharmacies (with the patient’s permission) to inform them of the patients who are having a surgery and their pre-admission clinic date

• Writing articles in local paper about this new initiative to inform patients

• Faxing community pharmacies a form to fax back so that it is completed in the hospital format as that you would use in hospital. (Note: some community pharmacies are using electronic version)

• Working with community pharmacists on discharge med rec form.


Innovations we’ve heard about……community

• Designated MedsCheck day - considered a viable business plan that pays for itself

• SPEP Students - good educational experience

• Scheduling daily time for MedsCheck

• BPMH training (Enhancing MedsChecks)

• Accommodating patients who cannot get a MedsCheck from their own pharmacy


Making it Happen

• What are the barriers in hospitals?

• What are the barriers in community to accommodating more patients for a MedsCheck or complying with patient/hospital request to book a MedsCheck?

• How can we work together?


Conclusion

We have opportunities

in Ontario to help

us overcome the

challenges of medication

information transfer


Questions

mcolquhoun or [email protected] or [email protected]

Documents

ISMP Canada ismp-canada