Initiatives

Providing medication cards for patients

• Several examples of hospital-provided med cards completed at discharge (Lahey, Cambridge, several others)
• Other hospital activities to raise awareness (media blitz, senior luncheons, pharmacy brown bags). Allan Frankel (IHI) raised concerns that this might not be the most productive short-term strategy for your reconciling team; don’t let your efforts here diffuse your efforts to address medication safety issues at your site
• Opportunity for statewide “universal medication list”? Coalition is currently investigating strategies for promoting wide-scale visibility of the importance of maintaining an accurate med list with both primary care physicians and consumers; a Coalition workgroup has collected numerous examples of med cards and developed a prototype card for further testing of content and format
• The Coalition has developed a prototype patient medication card for hospitals to use as a starting point in developing their own cards for patients. Keys to the card format include providing columns for key information about each medication (start date, name, dose/when to take, purpose, comments especially about danger signals and potential interactions, and monitoring needs); including space for OTCs and herbals as well as prescription medications; and allowing sufficient space for writing many medications in big-enough print.

Accelerating change

The September 15 Collaborative included extensive discussions about strategies for accelerating the adoption of reconciling processes. Expanded notes from this discussion will be added to this WEB site shortly. A few key points in summary:

Stress teamwork: There was a very eloquent plea from one of the participants for everyone to reframe their thinking about the reconciling process to focus on its implementation as a team effort. Bridge-building across disciplines is not promoted when existing boundaries and stereotypes are reinforced. This carried over into discussions about addressing resistance from different disciplines. MD engagement early on is an integral part of project success, but it is important to frame this initiative as an opportunity to improve communication between all the patient’s caregivers.

Use data/stories to engage leadership: Collect examples of errors reconciling could prevent such as omitted home meds and also evidence of orders changed, reconciling successes

Strategies for managing your team: Lots of discussion of what size team is too big, how to hold some meetings with active pilot unit team members rather than the full team list successful use of “huddles” but also not neglecting some scheduled meeting times.
Important contributions were mentioned by adding team members representing:

• IT support/Meditech
• Chief Medical Resident (with responsibility to report back to other residents)
• MD Champion (who was also head of the Medical Records Committee…)
• VNA
• Physician assistants
• Case managers
• Staff education

Importance, complexity of staff education: Many stories of problems that arose when reconciling forms showed up in patient charts where staff had not yet been introduced to the project. Reconciling needs to be embedded into daily processes. Develop process for communicating with non-pilot units. One creative example involved assigning all new MDs a reconciling buddy to learn the process.

Engaging the patient: Opportunities to use process as opportunity for patient education

Measurement

• Some strategies to deal with the time commitment of evaluating charts included:
  • Share the workload. Get an MD, an RN, and a Pharm to all do some of the charts.
  • Utilize night shift nurses. One IHI-hospital has developed a system that grants professional credits for doing chart audits. They trained night shift nurses in the process, and they loved it, as they were having a hard time getting enough prof credits!
  • Having RN managers from the implementing unit do the chart abstraction was much more successful for us than QA department who is not as close to the process; it went faster AND the managers learned so much about how reconciling was going, successes and issues to be addressed
  • Stretching out measurement to every 6 weeks
• A number of hospitals have reported supplemental measures that have been helpful in tracking their performance. Both hospital-wide and unit-level measures of the % of admissions with medications reconciled help capture the impact of rolling out to more patients on a unit, and then to new departments. Tracking # of medication orders changed and # home medications omitted provides examples of the success of reconciling it preventing errors.
• See FAQ on Data Collection Issues for more discussion on developing the core measure

JCAHO 2005 NPSGs Include Medication Reconciliation

JCAHO released its new 2005 National Patient Safety Goals (NPSGs) on July 20, 2004. Reconciling medications is included in the 2005 goals. This represents an active endorsement of the importance of the safety concepts behind the medication reconciliation practices embedded in the Massachusetts Coalition for the Prevention of Medical Error’s Reconciling Medications Collaborative. Hospitals participating in the Collaborative have already made great strides in identifying the best strategies for developing the patient’s home medication list at admission, using that list when the admit orders are written whenever possible, comparing the list to the actual orders written, and resolving any discrepancies between new orders and the home list that match their own organization workflow and processes.

Note that this safety process goes under a variety of different labels, including “reconciling medications”, “medication reconciliation”, “medication verification”, and “medication coordination”.

The wording in JCAHO’s final 2005 NPSG list:

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

• 8a: During 2005, for full implementation by January 2006, develop 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. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery]
• 8b: 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. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery]

Complete information on JCAHO’s 2005 NPSGs is available at:
http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm