- Email: [email protected]
Medication Reconciliation: Developing and Implementing a Program
Crit Care Nurs Clin N Am 18 (2006) 503–507
Medication Reconciliation: Developing and Implementing a Program Mandalyn Schwarz, RN*, Rhonda Wyskiel, RN, BSN Johns Hopkins Health System, Baltimore, MD, USA
Focusing on medication errors
Continuity of medication
The magnitude of the patient safety problem was publicly reported by the Institute of Medicine in 1999 [1]. In this report the Institute of Medicine challenged the health care community to change its systems of care delivery. One system that has been the focus of research for about 2 decades is medication errors and adverse drug events (ADE) [2–4]. The Harvard study found that one of five injuries or deaths was associated with a preventable ADE that resulted from a defective system that often lacked an independent redundancy [2]. Another prominent cause of ADEs was incorrect or incomplete transfer of medication information, particularly during transition in care [5–7]. Recently, US Pharmacopoeia (Rockville, MD) analyzed data from its MEDMARX reporting system and found 2022 reports of medication reconciliation errors between September 2004 and July 2005 [8]. Of these, 66% happened during transfer within the hospital, 22% during patient admission to a health care facility, and 12% at time of discharge. In efforts to reverse this trend, the Joint Commission on the Accreditation of Health care Organizations announced a new patient-safety goal in July 2004. This goal requires that hospitals ‘‘accurately and completely reconcile medications across the continuum of care,’’ beginning January 2006 [9]. An estimated 46% of medication errors occur at transition of care [5]. A recent study in a medical/surgical ICU found one medication error leading to a potential or actual ADE for every five doses of medication administered [10].
Ensuring continuity of medication administration in the hospital setting has been a challenge for health care providers, because new medications often are ordered and concurrent medications are changed or adjusted during hospitalization. In the complex setting of the ICU it is difficult to find time to record a patient’s home medications accurately. During most hospital stays, the patient’s home medications are not ordered. Few if any health care settings have recognized or taken the initiative to assess a patient’s home medications, checking for accuracy and continuing these medications in the ICU and on transfer, when appropriate. This article reports on an initiative aimed at ensuring administration of concurrent home medications and decreasing potential ADEs in transfer orders at the time of discharge from a surgical ICU.
* Corresponding author. E-mail address: [email protected] (M. Schwarz).
Medication reconciliation project Medication reconciliation is the process by which an accurate list of a patient’s home medications is compiled and compared with admission, transfer, and discharge orders. The concept of an independent redundancy was used to build the medication reconciliation process. An independent redundancy builds in checks, typically done by several care providers independent of one another, to ensure key processes are appropriately accomplished [11]. The concept of an independent redundancy was introduced and taught to staff in the Weinberg ICU at John Hopkins Health System, Baltimore Maryland, through ‘‘Science of Safety’’ lectures presented by the safety champion. The Science of Safety lecture and discussions
0899-5885/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2006.09.003
ccnursing.theclinics.com
504
SCHWARZ & WYSKIEL
heightened staff’s understanding that errors most often result from system malfunctions that can be corrected and prevented [1,12]. One high-risk system in health care that has the potential to cause errors occurs when patients are transitioned to other services or other care providers. Thus there is a need to focus on medication reconciliation to prevent ADEs. Needs assessment for medication reconciliation Baseline data were collected from July 1, 2001 through July 14, 2001 to determine the need for medication reconciliation in the ICU. A simple three-question tool was developed to assess the patient’s home medications, current ICU medications, and allergy information. Two nurses randomly audited 33 charts on discharging patients from the ICU. Of the 33 charts audited, 31 potential ADEs were identified. (Box 1) This process demonstrated that 94% of the unit’s patients were leaving the ICU with potential ADEs. These findings were discussed with the ICU directors, nurses, and physicians on the unit. Because of the prevalence of potential ADEs, it was decided to develop a medication reconciliation process. Developing the medication reconciliation process An improvement team was assembled that included the director of patient safety, a pharmacist, a nurse administrator, an ICU nurse, a representative from information systems, and the quality improvement administrator. The performance improvement committee members in the ICU were trained in the appropriate methods of data collection using ‘‘Plan, Do, Study, Act’’ methodology, a scientific method that is simple to use and broadly supported. During the ‘‘Plan’’ portion, the goals for the project are stated. During the ‘‘Do’’ and ‘‘Study’’ portion, small tests of change are implemented, and data analysis begins along with
Box 1. Potential adverse drug events found during collection of baseline data Missing cardiac medications: 8 Missing anticoagulant medications: 3 Missing synthroid dose: 1 Antibiotic orders: 7 Missing pain medications: 5 Missing allergy information: 5
displaying results. During the ‘‘Act’’ portion the change is built into the daily work processes, and staff is taught how to complete it [13]. The improvement team developed a tool that was used beginning on July 15, 2001 through May 1, 2002, called the ‘‘discharge survey,’’ to identify ADEs in patient transfer orders. The discharge survey was initiated during the admission process and completed on discharge for all ICU patients. To collect an accurate home medication list, the admitting nurse collected information from the patient and family and from the patient’s medical record, anesthesia report, and clinic notes. Initially the discharge survey listed all a patient’s prehospital medications, when they were last taken, whether they were reordered in the ICU, and whether they were ordered on transfer. Recognizing that some patients were taking nothing by mouth at certain points during this process, a place was added to document equivalent medications as well as whether restarted use of the medication was warranted or unwarranted at that time. At the end of the discharge survey, the authors asked several questions to identify potential ADEs: whether any discrepancies between ICU orders and transfer orders were found and corrected, whether any discrepancies between prehospital medications and transfer orders were found and corrected, and whether all allergies were listed correctly. This tool prompted ICU staff to notify the surgical or ICU team if any discrepancies were found. The final question on the survey asked if the transfer orders were changed. A changed order was considered a discrepancy or ADE. All discrepancies or potential ADEs were slated for immediate correction by notifying the primary care team, informing them of the reconciliation results, and asking whether the order should be changed. The medication reconciliation process was broken down into three steps: (1) initiation of the discharge survey at time of ICU admission, (2) updating of the medication history throughout the ICU stay; and (3) reconciling/completing the history and survey at time of discharge from ICU. The admitting nurse was expected to fill in all home medications accurately, and the next nurse was expected to fill in current ICU medications. Each shift updated the medication reconciliation tool, adding new medications and removing medications that were discontinued. At the time of discharge, if everyone was able to complete the expected tasks, the discharging nurse needed only to compare the discharge survey to transfer orders for accuracy.
MEDICATION RECONCILIATION
Barriers/facilitators during initial implementation There were many barriers to overcome while implementing this new process. First, it was difficult to schedule time for nurses to work on this safety initiative. The looming nursing shortage made it difficult to fit time away from the bedside into a nurse’s schedule. Nurses had to put in extra hours to perform the data collection and education required for this project to be a success. To obtain support from the staff, hours away from the bedside to complete the needed work were approved by management. The manager approved 4 to 12 hours per week for a project nurse to initiate and maintain this process. Fitting medication reconciliation into the daily care plan was another time constraint felt by the bedside nurse. This barrier was overcome by providing consistent support to nurses while they were becoming familiar with the process. Senior nurses, charge nurses, and performance improvement committee members became ‘‘super users’’ for medication reconciliation and provided assistance to complete the process efficiently and in a timely manner. The super users provided on-the-job, realtime assistance in completing this new process. Continual nurse feedback made it possible to adjust the tool to make it easier to enter data. Data collection proved to be difficult as medication reconciliation progressed. The authors realized that they needed education in data collection, tracking, and data analysis. They entered patient data on a spreadsheet that tracked the number of discrepancies found per patient. They also entered the total number of medications on each patient’s transfer list of medications to assist in determining the medication-based intervention rate. Lastly the medication reconciliation spreadsheet assisted in calculating the yearly cost savings. The authors were given technical support and guided through multiple data collection methods. Rigorous data collection has made it possible to spread medication reconciliation throughout the Johns Hopkins Hospital and to assist other hospitals in undertaking this project. Many Maryland hospitals have undertaken medication reconciliation as a safety initiative. Physician compliance was another barrier. The physician leader for the project, an ICU attending physician, overcame many obstacles with fellow doctors to enable adequate teaching to take place. Physicians were taught medication reconciliation as the process was developed. It was the responsibility of the primary-team physicians to
505
order all appropriate medications on the transfer orders and to verify whether it was appropriate to start the use of prehospital medications or to continue current ICU medications. Primary teams were called regarding discrepancies in medications and were asked to return to the unit to correct the orders if appropriate. This task was quite burdensome during their already hectic day. Physicians did not accept this added responsibility readily, and continual reinforcement from the nursing staff was required. Education of the physician housestaff continues to be ongoing, multifaceted, and supported by administration. Change is never easy, as was apparent during the beginning of medication reconciliation. Medication reconciliation impacted the work processes of the entire staff. Medication reconciliation was time consuming at first, and support and compliance were hard to achieve. The authors found that by sharing the dramatic results of their initial data collection and by educating unit clerks, pharmacists, and technicians as well as physicians and nurses they were able to ignite the change process. On May 1, 2002, an electronic version of the survey tool was added to the existing computer medical record or charting system used to manage in-patients, significantly decreasing the time required to complete the process. What initially took the nurse 30 minutes to complete, both on admission and discharge, now was completed in 15 minutes. Automating the tool increased nurse compliance by simplifying the process and placing the tool in an online system that nurses and physicians use to manage in-patients. In addition, nurses found that placing a copy of the medication history in the front of all patient charts enabled them to direct the primary care team to the list when the latter was writing transfer orders. Nurses also assisted when transfer orders were written to increase the accuracy of the medication list and to avoid paging the primaryteam physician as much as possible.
Data collection methods A potential ADE was any discrepancy between ICU orders and transfer orders, between prehospital medications and transfers orders, or accuracy of all allergies. Descriptives were measured, including the patient-based intervention rate and the medication-based intervention rate. The patient-based intervention rate measures the number of patients with at least one order changed as a result of
506
SCHWARZ & WYSKIEL
medication reconciliation. The medication-based intervention rate is the number of medications changed (numerator) based on medication reconciliation compared with all the medications ordered for ICU patients during a specific time period. Results Baseline data collection revealed that about 94% of ICU patients were leaving the unit with potential medication errors. By week 4 of implementing the medication reconciliation process, this rate was zero. The average patient-based intervention rate for 2005 was 31%, and the medication-based intervention rate for 2005 was 6%. The authors listed discrepancies by type and were able to focus on these areas for intervention and teaching (Fig. 1) Current status Medication reconciliation has become part of the everyday work process. It has been built into the computer charting system where it can be accessed by any member of the health care team. Using cultural change agents and patient safety
4%
8%
5%
Table 1 2005 cost avoidance Occurrence ratea Average cost of adverse drug eventa Yearly projection of medication-based interventions Estimated adverse drug events avoided (annualized) Estimated savings
3% $2182
4% $2182
6% $2182
512
512
512
15
20
31
$33,542 $44,723 $67,454
a
Estimate is an average of results from three independent studies.
champions and including the patient and families in their care have helped improve the practice. As with any process, it is not perfect, but it now works to improve the system of preventing ADEs for patients entering and leaving the ICU. Many hospitals nationwide are working on this initiative through the Institute for Health care Improvement and numerous collaboratives to improve quality and safety. Johns Hopkins Health System has recognized this process as vitally important to patient safety and has developed a collaborative dedicated to implementing this process into every point of entry and discharge that the patient meets. The true task is going to be automation of this system into provider order entry as all functional units transition to its use.
Cost savings associated with medication reconciliation 60%
23%
Another important benefit of initiating the medication reconciliation process has been the cost savings associated with the decrease in
Box 2. Week 1-25
Missing medication Wrong dose Wrong allergy Wrong medication
Average data collection days: 7 Number of data collection periods per year: 52.14 Average number of medication order-based interventions per period: 9.826923077 Average intervention rate: 6%
Inappropriate order
Fig. 1. Discrepancy types found upon medication reconciliation, Weinberg Intensive Care Unit, January 2005 to December 2005.
Yearly projections Medication-based interventions: 512.4038462
MEDICATION RECONCILIATION
potential ADEs. Based on review of literature, the estimated cost of an ADE is $2182 [5–7]. Using this information, the approximate annual cost savings for the ICU in the year 2005 has been calculated (Table 1, Box 2).
[2]
[3]
Summary During the past 5 years since the medication reconciliation process was formalized and automated, it has become an independent redundancy. The patient intervention rates are maintained at 30% to 35%, with ADE rates related to medication reconciliation at zero. The medication reconciliation process takes into account the accuracy and appropriateness of restarting prehospital medications and current ICU medications. It includes the omission of important home medications along with inaccuracies of dosages and frequencies. This form assures that the patient is receiving continuity of care and decreases complications of the patient’s health related to the changing of medications. Until recently this concept was disseminated by the staff without consistent administrative support. It was a process developed by nurses and perpetuated by nurses. Recently the administration has mandated that the process be implemented throughout the institution. A Hopkins health care–based collaborative is working to implement medication reconciliation hospital wide. The challenge exists in standardizing a process that is now specific to each functional unit. Multidisciplinary monthly meetings provide a forum for working through the barriers to incorporate these changes. This low-cost, high-impact safety initiative, if planned and performed strategically, can have a significant effect on patient safety. References [1] Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Institute of Medicine
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12] [13]
507
report. Washington (DC): National Academy Press; 1999. Leape L, Brennan T, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377–84. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324: 370–6. Bates DW, Cullen D, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995;5:29–34. Bates D, Spell N, Cullen D, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277:307–11. Rozich J, Resar R. Medication safety: one organization’s approach to the challenge. Journal of Clinical Outcomes Management 2001;8:27–34. Rozich JD, Howard RJ, Justeson JM, et al. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf 2004;30:5–14. Pharmacopeia US. Medication errors involving reconciliation failures. : USP Center for the Advancement of Patient Safety; 2005. Available at: www.jcipatientsafety.org/show.asp?durki=13419. Accessed February 27, 2006. Joint Commission on the Accreditation of Health care Organizations. Sentinel event alert. Using medication reconciliation to prevent errors. JCAHO 35. February 9, 2006. Available at: www.jcaho.org/ sentinelevents/sentineleventalert/sea35.htm. Accessed February 27, 2006. Kopp B, Erstad B, Allen M, et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med 2006;34:415–25. Pronovost PJ, Weast B, Schwartz M, et al. Medication reconciliation: a practical tool to reduce the risk for medication errors. J Crit Care 2003;18: 201–5. Reason J. Human error: models and management. BMJ 2000;320:786–90. Nelson T, Poe S. Rapid cycle safety improvement. Measuring Patient Safety 2005;4:39–49.
Medication Reconciliation: Developing and Implementing a Program Mandalyn Schwarz, RN*, Rhonda Wyskiel, RN, BSN Johns Hopkins Health System, Baltimore, MD, USA
Focusing on medication errors
Continuity of medication
The magnitude of the patient safety problem was publicly reported by the Institute of Medicine in 1999 [1]. In this report the Institute of Medicine challenged the health care community to change its systems of care delivery. One system that has been the focus of research for about 2 decades is medication errors and adverse drug events (ADE) [2–4]. The Harvard study found that one of five injuries or deaths was associated with a preventable ADE that resulted from a defective system that often lacked an independent redundancy [2]. Another prominent cause of ADEs was incorrect or incomplete transfer of medication information, particularly during transition in care [5–7]. Recently, US Pharmacopoeia (Rockville, MD) analyzed data from its MEDMARX reporting system and found 2022 reports of medication reconciliation errors between September 2004 and July 2005 [8]. Of these, 66% happened during transfer within the hospital, 22% during patient admission to a health care facility, and 12% at time of discharge. In efforts to reverse this trend, the Joint Commission on the Accreditation of Health care Organizations announced a new patient-safety goal in July 2004. This goal requires that hospitals ‘‘accurately and completely reconcile medications across the continuum of care,’’ beginning January 2006 [9]. An estimated 46% of medication errors occur at transition of care [5]. A recent study in a medical/surgical ICU found one medication error leading to a potential or actual ADE for every five doses of medication administered [10].
Ensuring continuity of medication administration in the hospital setting has been a challenge for health care providers, because new medications often are ordered and concurrent medications are changed or adjusted during hospitalization. In the complex setting of the ICU it is difficult to find time to record a patient’s home medications accurately. During most hospital stays, the patient’s home medications are not ordered. Few if any health care settings have recognized or taken the initiative to assess a patient’s home medications, checking for accuracy and continuing these medications in the ICU and on transfer, when appropriate. This article reports on an initiative aimed at ensuring administration of concurrent home medications and decreasing potential ADEs in transfer orders at the time of discharge from a surgical ICU.
* Corresponding author. E-mail address: [email protected] (M. Schwarz).
Medication reconciliation project Medication reconciliation is the process by which an accurate list of a patient’s home medications is compiled and compared with admission, transfer, and discharge orders. The concept of an independent redundancy was used to build the medication reconciliation process. An independent redundancy builds in checks, typically done by several care providers independent of one another, to ensure key processes are appropriately accomplished [11]. The concept of an independent redundancy was introduced and taught to staff in the Weinberg ICU at John Hopkins Health System, Baltimore Maryland, through ‘‘Science of Safety’’ lectures presented by the safety champion. The Science of Safety lecture and discussions
0899-5885/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2006.09.003
ccnursing.theclinics.com
504
SCHWARZ & WYSKIEL
heightened staff’s understanding that errors most often result from system malfunctions that can be corrected and prevented [1,12]. One high-risk system in health care that has the potential to cause errors occurs when patients are transitioned to other services or other care providers. Thus there is a need to focus on medication reconciliation to prevent ADEs. Needs assessment for medication reconciliation Baseline data were collected from July 1, 2001 through July 14, 2001 to determine the need for medication reconciliation in the ICU. A simple three-question tool was developed to assess the patient’s home medications, current ICU medications, and allergy information. Two nurses randomly audited 33 charts on discharging patients from the ICU. Of the 33 charts audited, 31 potential ADEs were identified. (Box 1) This process demonstrated that 94% of the unit’s patients were leaving the ICU with potential ADEs. These findings were discussed with the ICU directors, nurses, and physicians on the unit. Because of the prevalence of potential ADEs, it was decided to develop a medication reconciliation process. Developing the medication reconciliation process An improvement team was assembled that included the director of patient safety, a pharmacist, a nurse administrator, an ICU nurse, a representative from information systems, and the quality improvement administrator. The performance improvement committee members in the ICU were trained in the appropriate methods of data collection using ‘‘Plan, Do, Study, Act’’ methodology, a scientific method that is simple to use and broadly supported. During the ‘‘Plan’’ portion, the goals for the project are stated. During the ‘‘Do’’ and ‘‘Study’’ portion, small tests of change are implemented, and data analysis begins along with
Box 1. Potential adverse drug events found during collection of baseline data Missing cardiac medications: 8 Missing anticoagulant medications: 3 Missing synthroid dose: 1 Antibiotic orders: 7 Missing pain medications: 5 Missing allergy information: 5
displaying results. During the ‘‘Act’’ portion the change is built into the daily work processes, and staff is taught how to complete it [13]. The improvement team developed a tool that was used beginning on July 15, 2001 through May 1, 2002, called the ‘‘discharge survey,’’ to identify ADEs in patient transfer orders. The discharge survey was initiated during the admission process and completed on discharge for all ICU patients. To collect an accurate home medication list, the admitting nurse collected information from the patient and family and from the patient’s medical record, anesthesia report, and clinic notes. Initially the discharge survey listed all a patient’s prehospital medications, when they were last taken, whether they were reordered in the ICU, and whether they were ordered on transfer. Recognizing that some patients were taking nothing by mouth at certain points during this process, a place was added to document equivalent medications as well as whether restarted use of the medication was warranted or unwarranted at that time. At the end of the discharge survey, the authors asked several questions to identify potential ADEs: whether any discrepancies between ICU orders and transfer orders were found and corrected, whether any discrepancies between prehospital medications and transfer orders were found and corrected, and whether all allergies were listed correctly. This tool prompted ICU staff to notify the surgical or ICU team if any discrepancies were found. The final question on the survey asked if the transfer orders were changed. A changed order was considered a discrepancy or ADE. All discrepancies or potential ADEs were slated for immediate correction by notifying the primary care team, informing them of the reconciliation results, and asking whether the order should be changed. The medication reconciliation process was broken down into three steps: (1) initiation of the discharge survey at time of ICU admission, (2) updating of the medication history throughout the ICU stay; and (3) reconciling/completing the history and survey at time of discharge from ICU. The admitting nurse was expected to fill in all home medications accurately, and the next nurse was expected to fill in current ICU medications. Each shift updated the medication reconciliation tool, adding new medications and removing medications that were discontinued. At the time of discharge, if everyone was able to complete the expected tasks, the discharging nurse needed only to compare the discharge survey to transfer orders for accuracy.
MEDICATION RECONCILIATION
Barriers/facilitators during initial implementation There were many barriers to overcome while implementing this new process. First, it was difficult to schedule time for nurses to work on this safety initiative. The looming nursing shortage made it difficult to fit time away from the bedside into a nurse’s schedule. Nurses had to put in extra hours to perform the data collection and education required for this project to be a success. To obtain support from the staff, hours away from the bedside to complete the needed work were approved by management. The manager approved 4 to 12 hours per week for a project nurse to initiate and maintain this process. Fitting medication reconciliation into the daily care plan was another time constraint felt by the bedside nurse. This barrier was overcome by providing consistent support to nurses while they were becoming familiar with the process. Senior nurses, charge nurses, and performance improvement committee members became ‘‘super users’’ for medication reconciliation and provided assistance to complete the process efficiently and in a timely manner. The super users provided on-the-job, realtime assistance in completing this new process. Continual nurse feedback made it possible to adjust the tool to make it easier to enter data. Data collection proved to be difficult as medication reconciliation progressed. The authors realized that they needed education in data collection, tracking, and data analysis. They entered patient data on a spreadsheet that tracked the number of discrepancies found per patient. They also entered the total number of medications on each patient’s transfer list of medications to assist in determining the medication-based intervention rate. Lastly the medication reconciliation spreadsheet assisted in calculating the yearly cost savings. The authors were given technical support and guided through multiple data collection methods. Rigorous data collection has made it possible to spread medication reconciliation throughout the Johns Hopkins Hospital and to assist other hospitals in undertaking this project. Many Maryland hospitals have undertaken medication reconciliation as a safety initiative. Physician compliance was another barrier. The physician leader for the project, an ICU attending physician, overcame many obstacles with fellow doctors to enable adequate teaching to take place. Physicians were taught medication reconciliation as the process was developed. It was the responsibility of the primary-team physicians to
505
order all appropriate medications on the transfer orders and to verify whether it was appropriate to start the use of prehospital medications or to continue current ICU medications. Primary teams were called regarding discrepancies in medications and were asked to return to the unit to correct the orders if appropriate. This task was quite burdensome during their already hectic day. Physicians did not accept this added responsibility readily, and continual reinforcement from the nursing staff was required. Education of the physician housestaff continues to be ongoing, multifaceted, and supported by administration. Change is never easy, as was apparent during the beginning of medication reconciliation. Medication reconciliation impacted the work processes of the entire staff. Medication reconciliation was time consuming at first, and support and compliance were hard to achieve. The authors found that by sharing the dramatic results of their initial data collection and by educating unit clerks, pharmacists, and technicians as well as physicians and nurses they were able to ignite the change process. On May 1, 2002, an electronic version of the survey tool was added to the existing computer medical record or charting system used to manage in-patients, significantly decreasing the time required to complete the process. What initially took the nurse 30 minutes to complete, both on admission and discharge, now was completed in 15 minutes. Automating the tool increased nurse compliance by simplifying the process and placing the tool in an online system that nurses and physicians use to manage in-patients. In addition, nurses found that placing a copy of the medication history in the front of all patient charts enabled them to direct the primary care team to the list when the latter was writing transfer orders. Nurses also assisted when transfer orders were written to increase the accuracy of the medication list and to avoid paging the primaryteam physician as much as possible.
Data collection methods A potential ADE was any discrepancy between ICU orders and transfer orders, between prehospital medications and transfers orders, or accuracy of all allergies. Descriptives were measured, including the patient-based intervention rate and the medication-based intervention rate. The patient-based intervention rate measures the number of patients with at least one order changed as a result of
506
SCHWARZ & WYSKIEL
medication reconciliation. The medication-based intervention rate is the number of medications changed (numerator) based on medication reconciliation compared with all the medications ordered for ICU patients during a specific time period. Results Baseline data collection revealed that about 94% of ICU patients were leaving the unit with potential medication errors. By week 4 of implementing the medication reconciliation process, this rate was zero. The average patient-based intervention rate for 2005 was 31%, and the medication-based intervention rate for 2005 was 6%. The authors listed discrepancies by type and were able to focus on these areas for intervention and teaching (Fig. 1) Current status Medication reconciliation has become part of the everyday work process. It has been built into the computer charting system where it can be accessed by any member of the health care team. Using cultural change agents and patient safety
4%
8%
5%
Table 1 2005 cost avoidance Occurrence ratea Average cost of adverse drug eventa Yearly projection of medication-based interventions Estimated adverse drug events avoided (annualized) Estimated savings
3% $2182
4% $2182
6% $2182
512
512
512
15
20
31
$33,542 $44,723 $67,454
a
Estimate is an average of results from three independent studies.
champions and including the patient and families in their care have helped improve the practice. As with any process, it is not perfect, but it now works to improve the system of preventing ADEs for patients entering and leaving the ICU. Many hospitals nationwide are working on this initiative through the Institute for Health care Improvement and numerous collaboratives to improve quality and safety. Johns Hopkins Health System has recognized this process as vitally important to patient safety and has developed a collaborative dedicated to implementing this process into every point of entry and discharge that the patient meets. The true task is going to be automation of this system into provider order entry as all functional units transition to its use.
Cost savings associated with medication reconciliation 60%
23%
Another important benefit of initiating the medication reconciliation process has been the cost savings associated with the decrease in
Box 2. Week 1-25
Missing medication Wrong dose Wrong allergy Wrong medication
Average data collection days: 7 Number of data collection periods per year: 52.14 Average number of medication order-based interventions per period: 9.826923077 Average intervention rate: 6%
Inappropriate order
Fig. 1. Discrepancy types found upon medication reconciliation, Weinberg Intensive Care Unit, January 2005 to December 2005.
Yearly projections Medication-based interventions: 512.4038462
MEDICATION RECONCILIATION
potential ADEs. Based on review of literature, the estimated cost of an ADE is $2182 [5–7]. Using this information, the approximate annual cost savings for the ICU in the year 2005 has been calculated (Table 1, Box 2).
[2]
[3]
Summary During the past 5 years since the medication reconciliation process was formalized and automated, it has become an independent redundancy. The patient intervention rates are maintained at 30% to 35%, with ADE rates related to medication reconciliation at zero. The medication reconciliation process takes into account the accuracy and appropriateness of restarting prehospital medications and current ICU medications. It includes the omission of important home medications along with inaccuracies of dosages and frequencies. This form assures that the patient is receiving continuity of care and decreases complications of the patient’s health related to the changing of medications. Until recently this concept was disseminated by the staff without consistent administrative support. It was a process developed by nurses and perpetuated by nurses. Recently the administration has mandated that the process be implemented throughout the institution. A Hopkins health care–based collaborative is working to implement medication reconciliation hospital wide. The challenge exists in standardizing a process that is now specific to each functional unit. Multidisciplinary monthly meetings provide a forum for working through the barriers to incorporate these changes. This low-cost, high-impact safety initiative, if planned and performed strategically, can have a significant effect on patient safety. References [1] Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Institute of Medicine
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12] [13]
507
report. Washington (DC): National Academy Press; 1999. Leape L, Brennan T, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377–84. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324: 370–6. Bates DW, Cullen D, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995;5:29–34. Bates D, Spell N, Cullen D, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277:307–11. Rozich J, Resar R. Medication safety: one organization’s approach to the challenge. Journal of Clinical Outcomes Management 2001;8:27–34. Rozich JD, Howard RJ, Justeson JM, et al. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf 2004;30:5–14. Pharmacopeia US. Medication errors involving reconciliation failures. : USP Center for the Advancement of Patient Safety; 2005. Available at: www.jcipatientsafety.org/show.asp?durki=13419. Accessed February 27, 2006. Joint Commission on the Accreditation of Health care Organizations. Sentinel event alert. Using medication reconciliation to prevent errors. JCAHO 35. February 9, 2006. Available at: www.jcaho.org/ sentinelevents/sentineleventalert/sea35.htm. Accessed February 27, 2006. Kopp B, Erstad B, Allen M, et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med 2006;34:415–25. Pronovost PJ, Weast B, Schwartz M, et al. Medication reconciliation: a practical tool to reduce the risk for medication errors. J Crit Care 2003;18: 201–5. Reason J. Human error: models and management. BMJ 2000;320:786–90. Nelson T, Poe S. Rapid cycle safety improvement. Measuring Patient Safety 2005;4:39–49.