# Presentation: 947454

## Spotlight Case November 2005

**Reconciling Doses**

## Source and Credits

- This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
- See the full article at _[http://webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **Frank Federico**, **RPh**, Director, Institute for Healthcare Improvement
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*	**At the conclusion of this educational activity, participants should be able to:*
- List the steps involved in medication reconciliation
- Describe the role of each of the stakeholders in medication reconciliation
- Discuss how medication reconciliation decreases the opportunity for medication errors and harm

## Case: Reconciling Doses

*	**A 68-year-old man with a history of diabetes and atrial fibrillation (maintained on warfarin) presented to the emergency department (ED) with fever and mental status change. Lumbar puncture was attempted three times without success; empiric treatment for meningitis was started. Further examination revealed an area of cellulitis, and intravenous antibiotic therapy was changed accordingly.*

## Case (cont.): Reconciling Doses

- 	*At the time of admission, the patient was unable to recite his medication list, and his wife was unclear about the doses. However, the EMS run-sheet had a list of the patient’s medication and doses. The patient was started on the medication regimen per the EMS report. *

## Medication Reconciliation

- The process of collecting the best medication history possible, verifying that list, and comparing it with orders written at admission, transfer, and discharge
- Ensures each member of health care team has access to a list of home medications and what was ordered at transitions in levels of care
- Provides a method to communicate when an intentional medication change is made

## Medication Reconciliation: The Data

- More than one half of medication errors occur at the interfaces of care
- Up to 67% of cases had errors in prescription medication histories
- An average of 10 prescriptions needed to be changed weekly in the ICU as a result of implementing a reconciliation process

*Rozich JD, Resar RK. JCOM. 2001;8(10):27-34.**Tam VC, et al. CMAJ 2005;173:510-515.**Pronovost P. J Crit Care. 2003;18:201-205. *

## Medication Reconciliation

- Recommended change for teams participating in IHI collaboratives to reduce adverse drug events
- One of six changes chosen by the 100,000 Lives Campaign to improve patient care and prevent avoidable deaths
- JCAHO selected medication reconciliation as one of the National Patient Safety Goals

*100K Lives Campaign. IHI Web site. **National Patient Safety Goals for 2006 and 2005. JCAHO Web site. *

## Case (cont.): Reconciling Doses

*	**After 2 days, the patient was transitioned to Augmentin. While in hospital, the patient had been receiving 5 mg of warfarin at bedtime, which, according to the EMS intake sheet, was his usual outpatient dose. The team did not confirm this dose with the patient’s family, primary physician, or pharmacy. *

## Case (cont.): Reconciling Doses

- 	*At the time of discharge, the patient’s INR was noted to be 4.* *Realizing the warfarin dose was too high, the team instructed him to decrease his dose to 3 mg at bedtime and to have his INR rechecked in 3 days. After 3 days, his INR was 10. He was treated with vitamin K. *

## Case (cont.): Reconciling Doses

*	**Two days later, the patient returned to the ED with back pain, lower extremity weakness, and incontinence. He was found to have an epidural hematoma. The hematoma was emergently evacuated. One week post-operatively, the patient still had neurologic deficit.*

## Starting a Medication Reconciliation Program

- Identify a champion and a multidisciplinary team to work on testing changes that will lead to the desired system
- Ensure senior leadership support
- Secure commitment for resources for the project during its development
- Start with a small sample of the hospital population

## Recruiting Medication Reconciling Team

- Multidisciplinary team should include:
- Executive sponsor
- Physician champion
- Nursing leader, staff nurse
- Pharmacy leader, pharmacy support
- Patient safety/QI representative
- Staff education representative
- Other group representatives *(see form)*
- Team planning form available here

*Massachusetts Coalition for the Prevention of Medical Errors.*

## Examine the system currently in place
Use high-level flow diagram to determine the different entry points into the hospital 
Use similar diagram for transfers and discharges
Use a proven improvement methodology (eg, Model for Improvement) to test and implement changes

- Use high-level flow diagram to determine the different entry points into the hospital
- Use similar diagram for transfers and discharges
- Use a proven improvement methodology (eg, Model for Improvement) to test and implement changes

*Plsek PE. Pediatrics. 1999;103 (suppl):203-214.**Model for Improvement. IHI Web site.  *

**Developing a Medication Reconciliation Program**

## Developing the Reconciliation Process

- Identify who should participate in each step and define the responsibility of each position
- Medication history can be completed by a physician, nurse, pharmacist, or pharmacy technician
- Base decision on available resources
- Pharmacists found to be more effective in taking medication history but may train others to do so

*Michels RD, Meisel SB. Am J Health Syst Pharm. 2003;60:1982-1986.**Nester TM, Hale LS. Am J Health Syst Pharm. 2002;59:2221-2225.  *

## Potential Reconciliation Model

- RN collects medication history

- Pharmacist verifies information

- Physicians use the list to aid in decisions about drug therapy  and document reasons to discontinue, change, or hold medications

## Medication Reconciliation Forms

- Most organizations use forms
- Often adapted to serve as order form
- Columns can indicate whether medication should be continued, discontinued, or placed on hold
- Place the list prominently in the chart or use colored paper to facilitate access to information
- Hospitals must determine if these changes introduce new opportunities for errors

## Example Reconciliation Form

*http://www.macoalition.org/Initiatives/RecMeds/CooleyDickinsonReconcilForm.doc*

## Example Form (cont.)

- _[http://www.macoalition.org/Initiatives/RecMeds/CooleyDickinsonReconcilForm.doc](http://www.macoalition.org/Initiatives/RecMeds/CooleyDickinsonReconcilForm.doc)_

**Example Form (cont.)**

## Another Reconciliation Form

**Another Reconciliation Form**

- _[http://www.macoalition.org/Initiatives/RecMeds/CaritasNorwoodReconcilForm.doc](http://www.macoalition.org/Initiatives/RecMeds/CaritasNorwoodReconcilForm.doc)_

## Another Form (cont.)

*http://www.macoalition.org/Initiatives/RecMeds/CaritasNorwoodReconcilForm.doc*

## More Example Forms and Tools

- Massachusetts Coalition for the Prevention of Medical Errors
- Reconciling medication toolkit
- Institute for Healthcare Improvement
- Medication reconciliation tools

## Medication Reconciliation: Technology

- Linking electronic medical records to download medication histories onto a form reduces the number of steps and the need to manually complete form
- At discharge, reformatting the medication profile from the pharmacy system onto a prescription form can efficiently generate discharge prescriptions

## Evaluate Reconciliation Success

- Use a measurement strategy to determine program’s effectiveness
- Assessment form available here
- Collecting data per admission or chart may help determine if reconciliation is occurring
- Information about the percent of unreconciled medications at different transfer points can identify how well the process is working

## Medication Reconciliation: Role of the Patient

- Patients can be active participants in medication reconciliation
- Organizational level: One health system has engaged patients in developing a statewide universal medication form
- Individual level: Carry up-to-date medication list and present it at each health care visit
- Patient medication card available here

*Medication Reconciliation can Save Your Life. McLeod Health Web site. *

## How to Perform Medication Reconciliation

- Collect the best medication list possible
- If patient is unable to provide list, interview family members and contact primary physician or local pharmacy
- Complete medication reconciliation at each transition of care
- At discharge, reconcile prescriptions with most recent inpatient orders and patient medication list prepared at admission

## Take-Home Points

- Medication reconciliation is an effective process to reduce errors and harm associated with loss of medication information at transitions in care
- Collect the 'best' medication history possible; use open-ended questions when taking a medication history
- Patients can play a vital role in this process by carrying up-to-date medication list

## Take-Home Points

- Hospitals should develop medication reconciliation processes based on patient entry points and available resources
- Medication reconciliation should be applied whenever medication orders are rewritten or whenever there is a change in treatment plan or level of care
- For medication reconciliation to be successful, all stakeholders must be involved