UMass Memorial Medical Center

Medication ReconciliationEric Alper, M.D., Patient Safety Officer

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Our team:Our team:

Team Leader: Eric AlperTeam Leader: Eric AlperFaciliator: Faciliator: Jeanne Seligowski, Ellen Felkel-BrennanJeanne Seligowski, Ellen Felkel-BrennanPharmacy: Pharmacy: Christian Hartman, Thomas Magnant, Denis Christian Hartman, Thomas Magnant, Denis

Brown, Gerald LongenckerBrown, Gerald LongenckerNursing: Nursing: Anne Holland, Anne Smith, Gail Leger, Anne Holland, Anne Smith, Gail Leger,

Jacqueline Bergeron, Paulette Seymour-Jacqueline Bergeron, Paulette Seymour-Route (CNO)Route (CNO)

Sponsor: Sponsor: Gerald Steinberg (CQO)Gerald Steinberg (CQO)

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Medication errors based on Medication errors based on chart reviewchart review

56%

21%

14%

9%

Interface Errors

Drug Distribution orDocumentation ErrorsAllergy Documentation

Others

Source: Luther Midelfort Hospital -- Mayo Health System chart review

“We found that the list of medications that details current drug use was either nonexistent or wrong more than 85% of the time” [Rozich/Resar 2004, p.8]

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Examples of errorsExamples of errors

No orders for needed home meds No orders for needed home meds Surgeon inadequately addressing meds for Surgeon inadequately addressing meds for

chronic conditionschronic conditions Failure to restart meds at transfersFailure to restart meds at transfers Doubling up (brand/generic combinations, Doubling up (brand/generic combinations,

formulary substitutions)formulary substitutions)

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Problem identifiedProblem identified

Home med lists not systematically collectedHome med lists not systematically collected In multiple places in the chart, often incomplete In multiple places in the chart, often incomplete

or discordantor discordant Inadequate processes to compare list of pre-Inadequate processes to compare list of pre-

admit medications to ordersadmit medications to orders

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““Reconciling Medications”Reconciling Medications”

A A systematic process systematic process of creating the most of creating the most complete & accurate list possible of every complete & accurate list possible of every patient’s pre-admission medications and then patient’s pre-admission medications and then comparing that list against the physician’s comparing that list against the physician’s admission, transfer, and/or discharge orders. admission, transfer, and/or discharge orders. Discrepancies are brought to the attention of Discrepancies are brought to the attention of the physician and, if appropriate, changes are the physician and, if appropriate, changes are made to the orders. Any resulting changes in made to the orders. Any resulting changes in orders are documented.orders are documented.

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Our Engagement with Medication Our Engagement with Medication ReconciliationReconciliation Began early ’03Began early ’03

Joined IHI IMPACT Joined IHI IMPACT Mass Coalition convened CollaborativeMass Coalition convened Collaborative

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ProcessProcess

Designed pilot Designed pilot formform Designed pilot Designed pilot processprocess Multiple tests of change and Multiple tests of change and revisionsrevisions Gradually increased scopeGradually increased scope Broad educationBroad education

MeetingsMeetings Internal PublicationsInternal Publications

MeasurementMeasurement

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Process:Process: Wrote policyWrote policy Endorsement by Clinical Performance Improvement Endorsement by Clinical Performance Improvement

committee and Medical Staff Executive committeecommittee and Medical Staff Executive committee Revised related documentationRevised related documentation

Admission ordersAdmission orders Nursing Admission databaseNursing Admission database

Reviewed Medication reconciliation formReviewed Medication reconciliation form Completed Medication reconciliation formCompleted Medication reconciliation form

Discharge instruction module Discharge instruction module Continued MeasurementContinued Measurement Continued revisionContinued revision SharedShared

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Duplication orders and med history on database form are not required

LIST BELOW ALL OF THE PATIENT’S MEDICATIONS PRIOR TO ADMISSION INCLUDING OTC AND HERBAL MEDS DATE RECORDED:_________________________________

PHYSICIAN ORDER

MEDICATION NAME (WRITE LEGIBLY)

DOSE (mg, mcg, ?)

ROUTE (PO, GT, SC, IV)

FREQUENCY Last Taken

Select from: C to continue DC to discontinue Initial each order

Reconciled on

Admission

Reconciled on

Discharge

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Physician Signature__________________________ Print Name (legibly):____________________ Pager:________ Date/Time:_____________

PATIENT NAME: UNIT NUMBER:

MEDICATION RECONCILIATION AND ORDER FORM (Trial) Allergies: ___________________________________

Nurse Comments on Medications Nurse Signature:_________________________

Common Local Pharmacy Phone numbers:

Brooks-Grafton St. 508-798-9394 CVS-Shrewsbury 508-752-0439 #3 CVS-Grafton St. 508-752-6780 #3 CVS-Park Ave 508-792-3866 #3 Fallon 508-852-2866 Walgreens 508-767-1732

UMMMC : Univ ext: 62277 Memorial ext: 46356

Source of Medication list above: (check all used) Patient medication list Patient/Family recall Pharmacy _________________ Primary care physician list / PCHIS Previous discharge paperwork Medication Administration Record from facility Other: _______________________________

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ED

DC

Admission Medication Reconciliation Process for Elective Orthopedic andEmergent Medical through ED

Person 1

Admit andEligible?

PreadmissionVerification Form

in File or Pre Chart

1st Responder= AdmissionNurse or NP

Admission Nurse/NP Completes

YesNo

MD completes

PreadmissionVerification Form

Emergent Medical

YesNo

NursingUnit, FormFaxed to

Pharmacy

Person 1

PAT

PreadmissionVerification Form

Orthopedic?

RoutineAdmission

Documentation

Resident/MDwrites

medicationorders

Resident/MDCircles C or DCfor Medication

Orders

Resident/MDuses standingorders for new

medications

Elective

AdmissionMeds

reconciled

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Instructions for proper use: Admission: 1. A nurse, mid-level provider, or physician should take as thorough a medication history as possible. Consultation with the primary care physician,

pharmacy, and family members may be necessary to generate the most accurate medication list. 2. Upon admission, the physician/nurse practitioner/physician’s assistant responsible for the patient should carefully consider whether to continue

(C) or Discontinue (DC) each medication and circle the appropriate letters.. a. For medications that require dosage changes, the medication should be discontinued on this form, and the new dosage should be written

on the admission order sheet. b. For medications for which there exists a hospital therapeutic substitution, the medication should be discontinued and the new

medication to be substituted should be ordered on the admission order form. 3. Upon completion, the provider should sign and date on the M.D. signature line. This is now treated as a physician’s order. The form is scanned

to pharmacy and filed in the Orders section of the chart. 4. The nurse confirms the history with the patient and confirms proper transcription to the written Medication Administration record (Kardex) and

signs on the Nurse signature line. 5. Admission orders should indicate, “See reconciliation form.” All new medications to be started on admission should appear on the admission

order form. The History and Physical may indicate “See reconciliation form” in the Medications area. 6. If additional medication history is made available after the form has already been scanned to pharmacy, the medication history may be updated

by completing a second reconciliation form noting the addition or changes, and checking the Addendum/Revision box. Discharge: 7. At discharge, this form should be reviewed together with the Medication Administration Record (Kardex). The provider should carefully

consider whether each medication should be continued, resumed, or discontinued after the patient leaves the hospital. All medications and instructions should also be recorded on the discharge paperwork.

Pharmacy Phone Number Pharmacy Phone number Pharmacy Phone number

Memorial campus pharmacy 334-6356 CVS-Front St. 508-757-8118 CVS – Oxford 508 987-1327

University campus pharmacy 856-2277 CVS-Gold Star Blvd 508-852-0238 CVS – Westborough 508-898-9396

CVS-Grafton St. 508-793-0851 Fallon 508-852-2866

Beacon Pharmacy 508-754-4075 CVS-Holden 508-829-7631 Great Brook Valley 508-595-1128

Brooks- Dudley 508-949-0512 CVS-Leomimster 978-534-5114 Monahan 508-756-8300

Brooks-Chandler St. 508-754-5348 CVS-Lincoln Plaza 508-856-0211 Stop & Shop Grafton St 508-791-0070

Brooks-Grafton 508-839-6133 CVS-Lincoln St. 508-791-2579 Stop and Shop West 508 898 0427

Brooks-Greenwood Fair 508-752-1911 CVS-Marlboro 508-485-6119 Walgreens Lincoln St 508-852-2370

Brooks-Holden Main St. 508-829-6504 CVS-Millbury 508-865-8805 Walgreens Mill St 508-791-2111

Brooks-Millbury 508-865-0544 CVS-Park Avenue 508-752-0925 Walgreens Park Ave 508-767-1732

Brooks-Oxford 508-987-5386 CVS-Shrewsbury Spags 508-752-7721 WalMart- Hudson 978-568-3377

Brooks-Shrewsbury 508-842-8400 CVS-Spencer 508-885-3838 WalMart- Oxford 508-987-1111

Brooks-Sturbridge 508-347-7874 CVS-Webster 508-949-0641 WalMart Northboro 508-393-1745

CVS- Southwest Cutoff 508-793-1903 CVS-Webster Square 508-753-3297 WalMart-Whitinsville 508-234-9196

CVS-Auburn 508-832-6257 CVS-West Boylston 508-852-2406 West Side Pharmacy 508-754-4155

CVS-Chandler 508-798-0221 CVS –Grafton 508-839-2240

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Percent Medication Reconciliation, Presence of Form, and ADE Incidence Results Pilot Unit: South 3

2/1/03-4/1/04

020406080

100

020406080100

Percent Reconciled (All)

Percent ADE(s)

% Form in Record

Percent ADE(s) Pilot and SystemPercent ADE(s) Pilot and System

Method

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Percent Medication Reconciliation, Presence of Form, and ADE Incidence

System9/1/03-10/1/05

020

4060

80100

Sep-0

3

Oct

-03

Nov-0

3

Dec-0

3

Jan-

04

Feb-0

4

Mar

-04

Apr-0

4

May

-04

Jun-

04

Jul-0

4

Aug-0

4

Sep-0

4

Oct

-04

Nov-0

4

Dec-0

4

Jan-

05

Feb-0

5

Mar

-05

Apr-0

5

May

-05

Jun-

05

Jul-0

5

Aug-0

5

Sep-0

5

020

4060

80100

Percent Reconciled(All)

Percent ADE(s)

% Form in Record

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Patient Discharge InstructionsPatient Discharge Instructions

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LIST BELOW ALL OF THE MEDICATIONS THAT YOU ARE TAKING INCLUDING OVER THE COUNTER AND ALTERNATIVE REMEDIES. WRITE IF YOU DON’T KNOW OR CAN’T REMEMBER

ALL THE MEDICATIONS THAT YOU ARE TAKING. ALWAYS BRING A LIST OF EVERY MEDICATION YOU TAKE TO EVERY MEDICAL APPOINTMENT

Are you Pregnant? What pharmacy/pharmacies do you use? ________________________ Breastfeeding?

DOCTOR’S INSTRUCTIONS: WHAT TO DO AFTER YOU LEAVE?

MEDICATION NAME (WRITE LEGIBLY)

DOSE (How many mg,

mcg)

ROUTE (Mouth, Inhaled,

in nose)

HOW OFTEN? (once a day, twice a day, before meals)

How often do you actually take this medication?

CONTINUE STOP

TAKING CHANGE

Additional Instructions

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

MEDICATION HISTORY RECORDED/VERIFIED BY: ___________________________________________________

M.D. Signature ______________________________ Printed Name_____________________________________ Date____________

PATIENT NAME: UNIT NUMBER:

AMBULATORY MEDICATION RECONCILIATION FORM Today’s Date: _______________ Allergies: Medication Name Type of Reaction When?

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Shared our form and our Shared our form and our experience:experience: MA Coalition meetingsMA Coalition meetings IHI 100K Lives callsIHI 100K Lives calls Visited local hospitalsVisited local hospitals Spoken directly to VHA members (in Spoken directly to VHA members (in

Northeast, Connecticut, Pennsylvania, Northeast, Connecticut, Pennsylvania, Central, Central Atlantic, Pacific, Michigan, Central, Central Atlantic, Pacific, Michigan, Southwest regions)Southwest regions)

We (at UMass Memorial and MA We (at UMass Memorial and MA Coalition) have led the country Coalition) have led the country on this important means of on this important means of improving patient safetyimproving patient safety

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This project: This project:

Crossed the whole organizationCrossed the whole organization Required the knowledge and focus of Required the knowledge and focus of

thousands of individualsthousands of individuals Required repeated process redesign at Required repeated process redesign at

multiple levelsmultiple levels Has helped to start changing culture Has helped to start changing culture

around patient safetyaround patient safety

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In conclusion,In conclusion,

In this age of public reporting…In this age of public reporting… We all have “green dots” and “red dots”…We all have “green dots” and “red dots”…

At UMass Memorial, we are always striving to deliver At UMass Memorial, we are always striving to deliver safe, high quality care and to be leaders where we cansafe, high quality care and to be leaders where we can

Especially at this time, UMass Memorial genuinely Especially at this time, UMass Memorial genuinely appreciates this recognition as we try to continually appreciates this recognition as we try to continually improve health care for the people of Central MA and the improve health care for the people of Central MA and the CommonwealthCommonwealth