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Medication Reconciliation:The Inpatient Hospitalist Perspective

Peter Kaboli, MD, MSIowa City VAMC

CRIISP (Center for Research in the Implementation of Innovative Strategies in Practice)

University of Iowa, Iowa City, IA

AHRQ-Washington, D.C.

September 27, 2007

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JCAHO Definition of Med Reconciliation

• The process of comparing a patient's medication orders to all of the medications that the patient has been taking.

• This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

• It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.

• Transitions in care include changes in setting, service, practitioner or level of care.

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Is Med Reconciliation New?

• Absolutely not.

• JCAHO & IOM put it into the spotlight.

• Transitions of care have always been a problem.

• EMRs help, but don’t fix problem (VA).

• Fragmented care is the norm, even as far back as 1872.

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Beethoven's Doctor Accidentally Poisoned Him, Pathologist Claims

Wednesday, August 29, 2007

           

VIENNA, AUSTRIA —  DID SOMEONE KILL BEETHOVEN? A VIENNESE PATHOLOGIST CLAIMS THE COMPOSER'S PHYSICIAN DID — INADVERTENTLY OVERDOSING HIM WITH LEAD IN A CASE OF A CURE THAT WENT WRONG.OTHER RESEARCHERS ARE NOT CONVINCED, BUT THERE IS NO CONTROVERSY ABOUT ONE FACT: THE MASTER HAD BEEN A VERY SICK MAN YEARS BEFORE HIS DEATH IN 1827.

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Are Computerized Med Lists Accurate?

• 493 older veterans on >5 medications

• Pharmacist “brown bag” interview– Mean of 12.4 regularly scheduled meds

• range 5-49

• 8.0 Rx, 2.9 OTC, 1.5 vitamins/herbals

• Kaboli, et al. Assessing the Accuracy of Computerized Medication Histories, AJMC. 2004;10;872-877

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Agreement Definitions

• % of Patients with Perfect Agreement between the interview and computer

• Omissions: meds not on computer profile, but being taken by the patient

• Commissions: meds on the computer profile, but not being taken by the patient

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Findings• Only 5.3% of patients had perfect agreement

• Omissions:– 1.3 medications per patient

– 25% of all medications omitted

• Commissions:– 1.3 medications per patient

– 12.6% of all medications not being taken

• 23% of Allergies and 64% of ADEs missing

• Impossible to have 100% accuracy all the time

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Top 5 OmissionsBy Drug Class By Drug Name

Vitamins 26% Aspirin 10.4%

Anticoag/platelet 12% Multivitamin 8.2%

GI 12% Acetaminophen 6.7%

Herbals 9.2% Calcium 5.4%

Cardiovascular 8.2% Vitamin E 4.2%

34% of omissions were prescription drugs

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Top 5 Commissions

By Drug Class By Drug Name

Cardiovascular 16% Aspirin 5.0%

Derm/Topicals 13% Docusate 3.5%

GI 12% Diuretics 3.5%

Respiratory 9.3% Albuterol 3.1%

NSAID/COX-II 7.4% Tylenol 2.8%

66% of commissions were prescription drugs

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Other findings from our VA outpatient clinical pharmacist/physician intervention:

• Health literacy was associated with medication knowledge, but NOT with taking meds correctly or ADEs at 6 and 12 months.

• Outpatient pharmacist/physician evaluation can improve medication appropriateness, but hard to show improved clinical outcomes (ADEs).

• Patients are just as likely to NOT be taking a recommended medication as they are to be taken extra medications (polypharmacy).

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Implementing Med Reconciliation Kaboli, et al. Clinical Pharmacists and Inpatient Medical Care: A Systematic

Review. Arch Int Med, 166, May 8, 2006 • Clinical Pharmacists

– 11 RCTs of Admission and/or Discharge Med Reconciliation

– ↓ Preventable ADEs

– ↓ Time to input allergy information

– ↓ Readmission

– ↑ Medication knowledge

– ↑ Medication appropriateness

– ↑ Compliance

• Why wouldn’t a clinical pharmacist help?• Unfortunately not cheap or available 24-7

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Clinical Pharmacist InterventionSchnipper, et al. Role of Pharmacist Counseling in Preventing ADEs After

Hospitalization. Arch Int Med, 166, Mar 13, 2006. • Discharge counseling with 3-5 day

follow-up phone call (N=178).

– 30 day Preventable ADE rate 11% vs. 1%, but not all ADES

– Half of patients had discrepancies from pre-admit to discharge

– Did not improve medication adherence or ED/hospital re-admission

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Inpatient Clinical Pharmacists: Roles

• Careful review of med lists, including contacting local pharmacy if necessary

• Rounding with team, especially in ICU

• Make recommendations to inpatient team at admit and/or discharge

• Ensure patients get medications

• 3-5 day follow-up phone calls

• Are they “better” than physicians or nurses?

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What works for you?

• Clinical pharmacists

• Hospitalists

• Residents

• Nurses

• Pharmacy students

• Pharmacy techs

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Summary Keys for Success• Pharmacist and Physician champions

• Electronic or paper format

• Team accountability

• Involvement of patient/family– Health literacy and social support

• Discharge counseling

• Communication to primary care or SNF and outpatient pharmacy

• Follow-up phone call