Medicines reconciliation NHS Lothian ISMP Canada A few points for - PowerPoint PPT Presentation

Medicines reconciliation – NHS Lothian ISMP Canada

A few points for our WebEx today: Please dial in on your phone: 0800 389 7473 and then use the pass code: 955 297 50# If you are not presenting your phone is automatically on mute Phone lines will open at the end of the WebEx for Q and A with the presenters

To get involved in the conversation, please click on the Chat icon. Select All Participants from the drop down menu, type your message then click send. Introduce yourself. This WebEx is being recorded as a resource and will be available on the ihub website All Participants

WebEx Series for 2017 / 18 Transitions Omissions High risk meds

POLLING Question: Which of the following professions best describes you? 1. Patient / Service User 2. Medical 3. Nursing 4. Pharmacy 5. Other (please type in chat box)

SPSP Medicines Working to Improve Medicines Reconciliation Prepared by: on Discharge from Hospital Gillian Fulton Clinical Pharmacist Acute & Respiratory Medicine Royal Infirmary Edinburgh, NHS Lothian

Why MR on Discharge? • Pharmacy team spent HOURS every day correcting + + + errors on IDLs. • Care felt reactive and disorganised, with minimal time to proactively optimise care. Discharges were delayed. There wasn’ t much joy at work! • Baseline data collected in 10 patients per week over 10 weeks showed: – 72.5% of IDLs contained one or more medication errors – Average of 2.8 errors per IDL. • Adverse drug events known to occur in 20% patients following hospital discharge (1) and contribute to avoidable readmissions (2) . 1. Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers -getting the medicines right. Royal Pharmaceutical Society, London: 2012 2. Witherington EM et al. Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Qual Saf Health Care 2008;17:71-5

....We were definitely too busy to improve!

Measuremen t • Data collected prospectively in a random weekly sample of 10 patient IDLs: Process Measures: – Allergies – Changes to medicines from admission – Accurate list of medicines (HIS outcome measure) Outcome Measures: – Full compliance with process measures – (Categorised) error count • Moving to weekly data collection was vital step to improvement. Ensures data is built into routine and sensitive to change. • Attempted to categorise data according to potential risk of harm but was time consuming to collect and not sensitive enough to change.

Aim By June 2017, we will increase the proportion of patients whom have their medicines accurately reconciled on discharge from Ward 207 (a general medical ward) RIE to > 80% (Measure includes accurate documentation of allergies, changes and list of medicines on the IDL). In doing so, we will reduce medicine related errors on the IDL by 75% from baseline.

Med Rec on Discharge Element Compliance, Ward 207 100 90 80 % Compliance per 10 IDLs 70 60 50 40 30 20 10 Accurate List of Medicines Changes documented and correct Allergies documented and correct 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Study Week Number

P Chart: Proportion of IDLs with Full MR compliance on DC Percent PDSA Cycles included: 100% ① ECS filed with Kardex 90% ② Real time feedback 80% 70% UCL ③ Medicines Management Plan 60% (MMP) implemented 50% ④ Education sessions 40% ⑤ Pharmacy Triage Tool amended 30% 20% ⑥ R/V of TRAK controlled-drug files ① ② ③ ④ ⑤ ④ ⑦ ⑥ 10% ⑦ IDL template amended 0% LCL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Study Week Number

Count C Chart: Total number of MR errors per group of 10 IDLs PDSA Cycles included: 30 ① ECS filed with Kardex 25 ② Real time feedback ③ Medicines Management Plan 20 (MMP) implemented 15 ④ Education sessions LCL ⑤ Pharmacy Triage Tool amended 10 ⑥ R/V of TRAK controlled-drug files 5 ① ② ③ ④ ⑤ ④ ⑥ ⑦ ⑦ IDL template amended 0 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Study Week Number

Pareto Chart of Errors on IDL (31/10/16 - 27/11/16) Ward 207 25 100% 90% 20 80% 70% Cumulative % 15 60% Number 50% 10 40% 30% 5 20% 10% 0 0% Changes to medicines Drug Missing Wrong Wrong/incomplete Drug no longer CD requirements Duplication Allergies not Wrong dose Wrong/missing course not documented or formulation/device frequency required wrong/missing documented or length incorrect incorrect Pareto Chart of Errors on IDL (27/3/17 - 23/4/17) Ward 207 25 100% 90% 20 80% 70% Cumulative % 15 60% Number 50% 10 40% 30% 5 20% 10% 0 0% Drug Missing Wrong Changes to medicines CD requirements Wrong dose Wrong/incomplete Drug no longer Duplication Allergies not Wrong/missing course formulation/device not documented or wrong/missing frequency required documented or length incorrect incorrect

Give feedback freely… • BE POSITIVE (wherever you can) • ASK FOR HELP…

of regular feedback (and enthusiasm!) alone. Potential improvement in MR on discharge from one orthopaedic ward, RIE as a result Percent compliance Ward 209, RIE 100 10 20 30 40 50 60 70 80 90 0 31/… 07/… 14/… 21/… 28/… 04/… 11/… 18/… 25/… 02/… Full MR Compliance on Discharge 09/… 16/… 23/… 30/… 06/… 13/… 20/… 27/… 04/… 11/… #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A

Process Change: Medicine Management Plan (MMP)

Process Change: Amendment of IDL Template

Process Change: Amendment of Pharmacy Triage Tool Phar:1 Phar:D Med Rec completed: Y Med Rec completed : Y Sources used (min.of 2): ECS/Pods/Pt Sources used (min.of 2): Pt, ECS Outstanding Med Rec issues: NIL Outstanding Med Rec issues: nil Outstanding/ ongoing care issues: ? viral illness/beta Outstanding/ ongoing care issues: Rivaroxaban restarted, blocker side effect; bisoprolol restarted recently- dose now Haemoptysis resolved. Ceftriaxone stepped down to PO decreased during admission . co-amox. Digoxin level to be done pm (6 hours post dose) High Risk Medicines: Rivaroxaban High Risk Medicines : Apixaban (AF) Changes to medication: Spironolactone started, to complete Changes to medication: Bisoprolol decreased to 1.25mg 7/7 co-amox on d/c. Discharge/Compliance information: Dosette. Discharge/Compliance information: Independent S.H.C pharmacy. Tel: 453-4782 CP: 2283 contacted O/A

Successes and Cultural Change • Initial aims achieved with 87.5% reduction IDL medication errors on pilot ward • Amended IDL template implemented in AMU and all general medical wards • Wider MDT engagement with discharge MR compared to admission • 11 wards collecting discharge data across acute and general medicine, ICU, respiratory, general surgery, MoE, stroke and orthopaedics. • 9 wards collecting admission data across, acute and general medicine, ICU, general surgery, orthopaedics and women and children’s services. • Acute Medicine QIT established • Site wide MR working groups established across 3 acute adult sites, with focus on shared learning and policy development • Primary care links established to ensure system wide approach to improvement • QI project commenced in ICU to improve MR on DC from ICU

Ambitions & Next Steps • Spread and sustainability of improvement • Work with teams and eHealth to amend IDL templates in other specialties. • Ensure medication changes are reliably communicated to patients • INVOLE PATIENTS and work towards co-design of tools and improvement ideas • Focus on positive feedback in all areas collecting data • Work on our ‘marketing’ to make medicines QI more visible within secondary care in a bid to improve our safety culture • Collect and share patient stories, use emotional process mapping to capture hearts & minds • Use QI Life to encourage collaboration, communication and innovation • KEEP AT IT!

SPSP Medicines Prepared by: Margaret Colquhoun, R.Ph., B.Sc.Phm, FCSHP Aleksandra Stanimirovic, PhD Virginia Flintoft BN, MSc

Medication Reconciliation – Canadian Experience and Audit Tool

“ Safer Healthcare Now ” – 2005 - 2016 • Convergence of providers across Canada addressing safety interventions • MedRec > 500 teams, every province represented, • Developed MedRec Getting Started Kit including a new conceptual framework • 2010 - world-wide adoption of framework and measures • 2013 - identified a need a created a Quality Audit Tool • > 100 teams from across Canada reporting data monthly

Canadian MedRec Successes • < 50 bed hospitals to >1500 Beds • Small: “Personalize medication reconciliation as a local issue with baseline data”, “Strong leadership led to reliable processes across all interfaces” • Long Term Care: Full implementation across 62 LTC homes – “consistent use of data” • Large Institutions: Use of Pharmacy technician in taking BPMH’s , committed CEO, use of technology

Accreditation Canada (Health Standards Organization) Required Organizational Practice