Improving Patient Safety through Pharmacist- and Pharmacy Technician-Driven Medication Reconciliations at Transitions of Care

Improving Patient Safety through Pharmacist- and Pharmacy Technician-Driven Medication Reconciliations at Transitions of Care Julie H. McGinley, PharmD, MHS Southern Illinois University Edwardsville, School of Pharmacy

Disclosure and Conflict of Interest I, Julie H. McGinley declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

Pharmacist Objectives At the conclusion of this program, the pharmacist will be able to: 1. Explain why it is important to have pharmacists and/or pharmacy technicians involved in medication reconciliation (MR) at transitions of care (TOC). 2. Identify times when TOC MRs should occur. 3. Discuss strategies to implement a pharmacydriven MR program.

Technician Objectives At the conclusion of this program, the technician will be able to: 1. Identify high-risk medications which are more likely to lead to patient harm and may require a pharmacist s intervention. 2. Recognize directions for use (Sig codes) which require further clarification. 3. Describe the role of pharmacy technicians with regard to MR at TOC.

Pre-Test Question 1 1. Medication reconciliations at TOC are important because: a. The Joint Commission has designated inpatient medication reconciliation as a National Patient Safety Goal b. Errors such as omissions and duplications, dosing changes and new drug-drug interactions can significantly compromise patient safety c. Readmission rates and medication errors decline overall when medications are reconciled d. All of the above

Pre-Test Question 2 1. When should a TOC medication reconciliation occur? Choose all that apply: a. Upon emergency department admission b. Upon inpatient admission c. Upon transfer from one unit to another d. Upon transfer from one room to another within the same unit

Pre-Test Question 3 1. Which medication falls into a high-risk class and may require a pharmacist s intervention if there is a discrepancy noted during the medication reconciliation? a. apixaban b. hydrocodone c. glipizide d. All of the above

Pre-Test Question 4 1. Which directions for use (Sig codes) require further clarification according to the Institute for Safe Medication Practices (ISMP)? Choose all that apply: a. MgSO 4 4.0g IV qd b. lisinopril 40 mg po daily c. APAP 500 mg po q 4 6 hours PRN pain d. lorazepam.5 mg po qhs

Background Adverse drug events (ADEs) are at the greatest risk of occurring during care transitions There is a reported range of inpatient medication errors from 45% - 76% The Joint Commission and National Patient Safety Goal 03.06.01 In medication reconciliation, a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies. American College of Clinical Pharmacy, et al. Pharmacotherapy. 2012 Nov;32(11):e326-37. Sen S, et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):51-6. The Joint Commission. Hospital National Patient Safety Goals; 2015.

Definitions Medication Reconciliation: A clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies. The process of creating the most accurate list possible of all medications a patient is taking including drug name, dosage, frequency, and route and comparing that list against the physician s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital. The Joint Commission. Hospital National Patient Safety Goals; 2015. Institute for Healthcare Improvement. 2016.

Definitions Transitions of Care: At admission, transfer, and discharge Transitions in care both within and outside of an organization A transfer of care At admission (both into the Emergency Department and then to inpatient status) At transfer of care within the hospital (to a different unit or new care provider) At discharge Institute for Healthcare Improvement. 2016. The Joint Commission. Hospital National Patient Safety Goals; 2015.

HSHS St. Elizabeth s Hospital Belleville, Illinois Community-based teaching institute Decentralized pharmacy model with inter-professional patient rounds and clinical pharmacy services Dedicated Emergency Department Pharmacist Dedicated Emergency Department Pharmacy Technicians

Why Pharmacy? Pharmacists are consistently ranked Pharmacists as one Pharmacists of are the the most are trusted the accessible of all MEDICATION professions health care by professionals. EXPERTS. Gallup. www.pinterest.com ml-law.net Ml-law.net www.pintrest.com www.outcomeresources.com

Data Supporting Pharmacy Gleason and colleagues estimated that the cost of potential harm avoided by pharmacists conducting medication reconciliation was almost $39,000 Gleason et al. Am J Health Syst Pharm. 2004 Aug 15;61(16):1689-95. Gleason et al. J Gen Intern Med. 2010 May;25(5):441-7. Schnipper et al. Arch Intern Med. 2006 Mar 13;166(5):565-71.

Data Supporting Pharmacy In the MATCH study, physician-obtained medication history was the source of error more often than in pharmacist-obtained medication histories Gleason et al. Am J Health Syst Pharm. 2004 Aug 15;61(16):1689-95. Gleason et al. J Gen Intern Med. 2010 May;25(5):441-7. Schnipper et al. Arch Intern Med. 2006 Mar 13;166(5):565-71.

Data Supporting Pharmacy Schnipper and colleagues found that when a pharmacist provided discharge counseling and follow-up with a pharmacist, readmissions and emergency department visits decreased significantly from 8% to 1% Gleason et al. Am J Health Syst Pharm. 2004 Aug 15;61(16):1689-95. Gleason et al. J Gen Intern Med. 2010 May;25(5):441-7. Schnipper et al. Arch Intern Med. 2006 Mar 13;166(5):565-71.

Data Supporting Pharmacy Levitz found that after 2 years of pharmacy technicians conducting medication reconciliations, the medication error rate decreased from 50% to <5% Levitz MD. Pharmacy Times. 2013 August. Sen et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):51-6. Michels et al. Am J Health Syst Pharm. 2003 Oct 1;60(19):1982-6.

Data Supporting Pharmacy Sen et al demonstrated that a pharmacy technician-centered MR (PTMR) program identified a similar number of discrepancies as when pharmacist-conducted Levitz MD. Pharmacy Times. 2013 August. Sen et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):51-6. Michels et al. Am J Health Syst Pharm. 2003 Oct 1;60(19):1982-6.

Data Supporting Pharmacy Michaels and colleagues decreased potential ADEs by > 80% by having a pharmacy technician conduct the medication reconciliation Levitz MD. Pharmacy Times. 2013 August. Sen et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):51-6. Michels et al. Am J Health Syst Pharm. 2003 Oct 1;60(19):1982-6.

Getting Started 1. Policy and Procedure Development 2. Implementation and Performance Improvement 3. Training and Competency Assurance 4. Information Systems Development 5. Advocacy American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2013;70:453-6.

Getting Started- Planning 1. Location Location Location - A specific unit - A specific disease state - A specific transition 2. Who will be involved - Pharmacist - Pharmacy Technician - Nurses/Managers/Physicians - Patient American Society of Health-System Pharmacists et al. Best practices from the ASHP-APhA medication management in care transitions initiative. 2013 Feb.

Getting Started- Planning 3. Determine current Medication Reconciliation Work Flow - Don t duplicate efforts 4. Look for Areas to Improve/Streamline Work Flow 5. Pick a Date for Implementation American Society of Health-System Pharmacists et al. Best practices from the ASHP-APhA medication management in care transitions initiative. 2013 Feb.

Common Barriers 1. Cost 2. Manpower 3. Increased Workload 4. Appropriate Training 5. Lack of standardized discharge order cut-off time 6. Technological Barriers 7. Lack of Continuity to the Ambulatory Care Setting American Society of Health-System Pharmacists et al. Best practices from the ASHP-APhA medication management in care transitions initiative. 2013 Feb.

Technology

Use of Pharmacy Technicians Choose Pharmacy Technicians with experience Strong communication skills are necessary Adequate supervision during training Clear work flow process and when pharmacist involvement is required Documentation Michels et al. Am J Health Syst Pharm. 2003 Oct 1;60(19):1982-6. Sen et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):51-6.

Use of Pharmacy Technicians Date Tech Column1 # of Meds Missing Documentation w/ Alert Missing Documentation w/o Alert Meds with Complete Documentation Last Taken Field Not Addressed Last Taken Field Addressed Total Errors Error Rate Auditing Comments Jan-16 7 0 1 0 0 0 1 0.071428571INPUT MILK OF MAGNESIUM PRN CONGESTION Jan-16 19 0 0 19 0 19 0 0 Jan-16 14 0 0 14 0 14 0 0 Jan-16 19 0 0 19 0 19 0 0 Jan-16 15 0 0 15 0 15 0 0 Jan-16 16 0 0 16 0 16 0 0 Jan-16 9 0 0 9 0 9 0 0 Jan-16 4 0 0 4 0 4 0 0 Jan-16 3 0 0 3 0 3 0 0 Jan-16 11 0 0 11 0 11 0 0 0 0 0 0 Jan-16 4 0 0 4 1 3 1 0.125 Jan-16 3 0 0 3 0 3 0 0 Jan-16 28 0 0 28 3 25 3 0.053571429 Jan-16 15 0 0 15 5 10 5 0.166666667 Jan-16 3 0 0 3 0 3 0 0 Jan-16 6 0 0 6 0 6 0 0 Jan-16 4 0 0 4 0 4 0 0 Jan-16 8 0 0 8 0 8 0 0 Jan-16 14 0 0 14 6 8 6 0.214285714 Jan-16 25 0 0 25 0 25 0 0 0 0 0 0 Jan-16 4 0 0 4 0 4 0 0 Jan-16 4 0 0 4 0 4 0 0 Jan-16 14 0 0 14 1 13 1 0.035714286 Jan-16 4 0 0 4 0 4 0 0 Jan-16 7 0 0 7 0 7 0 0 Jan-16 4 0 0 4 0 4 0 0 Jan-16 3 0 0 3 0 3 0 0 Jan-16 11 0 0 11 0 11 0 0 Jan-16 0 0 0 0 0 0 0 0 Jan-16 11 0 0 11 0 11 0 0 0 0 0 0

Use of Pharmacy Technicians Date Tech Medical Record # Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician Jan-16 Sally Smith, Technician

Use of Pharmacy Technicians DateTech Medical Record # of # Meds Missing Docum entatio n w/ Alert Missing Documen tation w/o Alert Meds with Complete Documen -tation Last Taken Field Not Addressed Last Taken Field Addressed Total Errors Error Rate Jan- 16 7 0 1 6 0 7 1 0.07 Jan- 16 19 0 0 19 0 19 0 0 Jan- 16 14 0 0 14 0 14 0 0 Jan- 16 19 0 0 19 0 19 0 0 Jan- 16 15 0 0 15 0 15 0 0 Auditing Comments INPUT MILK OF MAGNESIUM PRN CONGESTION

Use of Pharmacy Technicians

Use of Pharmacy Technicians DateTech Medical Record # of # Meds Missing Docum entatio n w/ Alert Missing Documen tation w/o Alert Meds with Complete Documen -tation Last Taken Field Not Addressed Last Taken Field Addressed Total Errors Error Rate Jan- 16 7 0 1 6 0 7 1 0.07 Jan- 16 19 0 0 19 0 19 0 0 Jan- 16 14 0 0 14 0 14 0 0 Jan- 16 19 0 0 19 0 19 0 0 Jan- 16 16 0 0 16 2 14 2 0.0625 Auditing Comments INPUT MILK OF MAGNESIUM PRN CONGESTION

Use of Pharmacy Technicians

Use of Pharmacy Technicians High Alert Medications Antiarrhythmics Antithrombotics Chemotherapeutic Agents Hypoglycemics, oral and IM Insulins Opioids Institute for Safe Medication Practices. https://www.ismp.org/tools/errorproneabbreviations.pdf. Accessed June 10, 2016. Institute for Safe Medication Practices. https://www.ismp.org/tools/highalertmedications.pdf. Accessed June 10, 2016.

Use of Pharmacy Technicians Error-Prone Abbreviations, Symbols and Dose Designations qd qhs U 1.0.5 Inderal40 10mg MgSO 4 APAP Institute for Safe Medication Practices. https://www.ismp.org/tools/errorproneabbreviations.pdf. Accessed June 10, 2016. Institute for Safe Medication Practices. https://www.ismp.org/tools/highalertmedications.pdf. Accessed June 10, 2016.

Next Steps HSHS Medical Group Ambulatory Care Clinic Focus on medication reconciliation from inpatient to outpatient Report back

Post-Test Question 1 1. Medication reconciliations at TOC are important because: a. The Joint Commission has designated inpatient medication reconciliation as a National Patient Safety Goal b. Errors such as omissions and duplications, dosing changes and new drug-drug interactions can significantly compromise patient safety c. Readmission rates and medication errors decline overall when medications are reconciled d. All of the above

Post-Test Question 2 1. When should a TOC medication reconciliation occur? Choose all that apply: a. Upon emergency department admission b. Upon inpatient admission c. Upon transfer from one unit to another d. Upon transfer from one room to another within the same unit

Post-Test Question 3 1. Which medication falls into a high-risk class and may require a pharmacist s intervention if there is a discrepancy noted during the medication reconciliation? a. apixaban b. hydrocodone c. glipizide d. All of the above

Post-Test Question 4 1. Which directions for use (Sig codes) require further clarification according to the Institute for Safe Medication Practices (ISMP)? Choose all that apply: a. MgSO 4 4.0g IV qd b. lisinopril 40 mg po daily c. APAP 500 mg po q 4 6 hours PRN pain d. lorazepam.5 mg po qhs PRN sleep MgSO 4 can be confused for MSO 4 ; never put a trailing zero after decimal point; always put a space between dose and unit of measure; never use qd as it can be mistaken for qid APAP may not be recognized as acetaminophen Always use a leading zero prior to the decimal point; qhs should not be used as it can be confused with qhr or half-strength

Acknowledgements Pharmacy staff at HSHS St. Elizabeth s Hospital Michael Randazzo, PharmD

References American College of Clinical Pharmacy, Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, Kennedy AK, LaPointe NM, Burkhardt CD, Schilli K, Seaton T, Trujillo J, Wiggins B. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012 Nov;32(11):e326-37. American Pharmacists Association, American Society of Health-System Pharmacists, Steeb D, Webster L. Improving care transitions: optimizing medication reconciliation. J Am Pharm Assoc. 2012 Jul-Aug;52(4):e43-52. American Society of Health-System Pharmacists, American Pharmacists Association, Cassano A. Best practices from the ASHP-APhA medication management in care transitions initiative. 2013 Feb. American Society of Health-System Pharmacists. ASHP statement on the pharmacist s role in medication reconciliation. Am J Health-Syst Pharm. 2013;70:453-6. Erickson AK. Transitions of care: the next frontier for hospital and community-based pharmacist. Pharmacy Today. 2016 April;22(4):34-7. Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at transitions and clinical handoffs (MATCH) toolkit for medication reconciliation. AHRQ Publication No. 11(12)-0059. Rockville, MD: Agency for Healthcare Research and Quality. December 2011. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004 Aug 15;61(16):1689-95. Gleason KM, McDaniel MR, Feinglass J, Baker DW, Lindquist L, Liss D, Noskin GA. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010 May;25(5):441-7. Hall S. Case Study: medication reconciliation by pharmacy technicians, student interns. Pharmacy Practice Model Initiative. http://www.ashpmedia.org/pai/docs/casestudy_lincolnhospital.pdf. Accessed June 14, 2016.

References Institute for Safe Medication Practices. ISMP s list of error-prone abbreviations, symbols, and dose designations. https://www.ismp.org/tools/errorproneabbreviations.pdf. Accessed June 10, 2016. Institute for Safe Medication Practices. ISMP s list of high-alert medications in acute care settings. https://www.ismp.org/tools/highalertmedications.pdf. Accessed June 10, 2016. Levitz MD. Medication reconciliation: the role of the pharmacy technician. Pharmacy Times. 2013 August. http://www.pharmacytimes.com/publications/directions-in-pharmacy/2013/august2013/medication-reconciliation-the-role-of-the-pharmacytechnician. Accessed June 10,2016. Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm. 2003 Oct 1;60(19):1982-6. Sen S, Bowen JF, Ganetsky VS, Hadley D, Melody K, Otsuka S, Vanmali R, Thomas T. Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings. Pharm Pract. 2014 Apr;12(2):439. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, Kachalia A, Horng M, Roy CL, McKean SC, Bates DW. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006 Mar 13;166(5):565-71. Sen S, Siemianowski L, Murphy M, McAllister SC. Implementation of a pharmacy technician-centered medication reconciliation program at an urban teaching medical center. Am J Health Syst Pharm. 2014 Jan 1;71(1):51-6. The Joint Commission, The Joint Commission International, World Health Organization. Assuring medication accuracy at transitions in care. Patient Safety Solutions. 2007 May;1(6)

Speaker Contact Information Julie H. McGinley, PharmD, MHS 618-650-5954 juheine@siue.edu