SPhoto by Charles Williams - Creative Commons Attribution License http://www.flickr.com/photos/99652207@N00 Created with Haiku Deck

2

S

Med Wreck to Med Rec

.

What is the problem?

Hospitalized patients who experience an adverse drug event (ADE) are twice as likely to die as those without an ADE (JAMA 1997; 277:301-306)

The Institute of Medicine has estimated that medication errors account for 7,000 deaths annually (To Error Is Human: building a safer health system, 1997, IOM)

ADEs account for 6.3% of malpractice claims (Arch Intern Med. 2002; 162:2414-2420)

Scope of the Problem – Admission

Comish, et al. Arch Intern Med. 2005;165:424-9

151 patients in a study (at least 4 prescription medications)

53 % had at least one unintended discrepancy

Omission was the most common error

38 % of the discrepancies had the potential to cause serious to moderate harm

6

What Happened?

Swiss Cheese Model of Major Errors

Reason J. Human error: models and management. BMJ. 2000;320:768-770.

Transcription errorDC meds not

reviewed

Pt/care giver does not review meds

Outpt doc

unaware of

change

Sentinel Event

Admission

IOM: To Err is Human

1999- Institute of Medicine’s (IOM) report

98,000 deaths annually in hospitals

1.5 Million Potential ADEs (1/day/pt)

9000 deaths from adverse drug events

Most errors are system based, not due to reckless

individuals

SPhoto by mcmorgan08 - Creative Commons Attribution-ShareAlike License http://www.flickr.com/photos/27850158@N02 Created with Haiku Deck

SPhoto by US Army Africa - Creative Commons Attribution License http://www.flickr.com/photos/36281822@N08 Created with Haiku Deck

SPhoto by gazzat - Creative Commons Attribution-NonCommercial-ShareAlike License http://www.flickr.com/photos/57557325@N00Created with Haiku Deck

SPhoto by kylepost - Creative Commons Attribution License http://www.flickr.com/photos/46244456@N02 Created with Haiku Deck

SPhoto by xavi talleda - Creative Commons Attribution-NonCommercial-ShareAlike License http://www.flickr.com/photos/46527925@N04Created with Haiku Deck

14

A well designed process is:

It uses a patient-centered approach

The process is easy to complete by all involved. Staff recognize the importance

It minimizes opportunity for drug interactions and therapeutic duplications by making the patient’s list of home medications available to all prescribers

It provides the patient with an up-to-date list of medications

It ensures that providers who need to have information about changes in the medication plan get that information

15

Challenges

There is no clear owner of the process. There is no standardized process to ensure that the

patient’s home medication list is available to all providers and compared with the most recent list of medications as patients move through different levels of care

Physicians are reluctant to order medications that may be unfamiliar to them or that have been prescribed by others

Staff do not have the time to complete each of the steps in the process

The focus has been on completing a form rather than meeting the intent of the intervention

There are many situations in which the patient may not know or can’t provide a list of medications.

Accurate sources of information may be difficult to identify The original medication list isn’t linked to the physician

orders as the patient transitions from one location to another.

16

‘One source of truth’

17

18

PRECEDE-PROCEDE

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Adapted from: The Institute for Healthcare Improvement

The PDSA Cycle

Act

• What changes are to be made?• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

Medication reconciliation program TimelineMonth 1 Month 2 Month 3

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Shadowing on UnitsKickoff & Team Orientation

Escalation PlanningLong Term Action Plan TrackingLive Metric Tracking

Plan Do Study

Activity

Progress Review # 2

Hospital Analyst TrainingSolution Tracker Updated WeeklyPrioritized Solution Implementation

Baseline Analyses Complete

Quick Win ImplementationProgress Review # 1Solution Prioritization & PlanningSolution DevelopmentRoot Cause AnalysisPain Point PrioritizationPain Point IdentificationProcess Mapping

Act/ Sustain

Initial Leadership Meetings

Baseline Establishment & Goal Setting

Prioritized Solution Approval

Solution Implementation

Issue Identification & Prioritization

Sustainability

22

Nursing intervention

Education about BPMH

Education about charting in HED

Education about sources of information

Flyers

Champions

23

24

Physician intervention

Education in doing med rec in 24 hours

High risk meds in 4 hours

On call physician to cooperate

Discrepancy clarification

25

Pharmacy intervention

Educating pharmacist to make changes in HHS

Contacting outside pharmacy

Helping nurses in discrepancy

26

Patient intervention

Signage in ED about bringing home meds

Wallet medication card

Education flyers in the room next to communication boards

Discharge education in regards to PCP.

27

IT intervention

Glitch in system regarding indications, last dose taken etc.

Nurses access to HPF (past medical record)

28

Policy intervention

Clarifying roles in policy

Addition of flow map

Addition of high risk medication rule.

29

Outcome

The measurable outcomes of the program are: Increased staff and patient satisfaction. Reduced readmission rates secondary to medication

reconciliation. Increased communication with PCP at discharge. Reduced adverse drug events causing harm to the patient

secondary to prevention of medication errors. Medication reconciliation completed 100% of the time and

addressed by MD within 24 hours. Zero discrepancy in the home medication list. Nurses able to interview patient regarding the BPMH. Secondary outcomes include reduced cost, increase

quality of life, adequate refills etc.