Continuity of Medication Management

Spreading Medication Reconciliation Improvements

HospitalPresenterMonth YYYY

Continuity is an Issue in Health Care

• 10-67% of medication histories contain at least one error1

• Incomplete medication histories at the time of admission have been cited as the cause of at least 27% of prescribing errors in hospital2

• The most common error is the omission of a regularly used medicine3

• Around half of the medication errors that happen in hospital occur on admission or discharge4

• 30% of these errors have the potential to cause harm3,5

Local Examples - Medication Errors

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e.g. contributed to

death>

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<Insert resulting effect on patient>

<Insert consequence e.g. caused

moderate to severe harm>

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<Insert resulting effect on patient>

<Insert consequence e.g. caused

minor harm>

Quality Improvement

• <Insert name of ward/unit>

• <Insert names of Quality Improvement team members>

• <Insert Aim Statement>

Specific, Measurable, Aspirational, Realistic, Time based

Diagnosis of Problem

• <Insert process undertaken e.g.- Process flow chart- Brainstorming- Ishikawa (cause and effect) diagram- Prioritising causes - Weighted voting - Pareto chart>

Problem Work Flow

• <Insert copy of flow chart>

Ishikawa (Cause and Effect) Diagram

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Insert cause

Insert group name

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Prioritising Causes

• <Insert copy of Pareto chart>

Highest Scoring Causes

• <Insert a description of each of the highest scoring causes on the Pareto chart>

Agreed Strategies

• <Insert agreed strategies and work plan>

Improvements

• <Insert improvement results e.g. run charts>

Lessons Learned

• <Insert what worked well, and what didn’t work well>

Strategies for Sustaining Improvements

• <Insert strategies e.g.- Real time measuring and reporting- Continual training of new staff- Ingraining as standard process- Documentation of procedure, protocols and

guidelines- Encourage feedback- Continually review and refine using feedback>

Strategies for Spread

• <Insert strategies e.g.- Form unit/ward quality improvement team- Compare existing process to trial teams experience

- Are there any differences requiring consideration?- Review previous teams results

- Are causes similar?- Are strategies achievable?

- Trial existing or adapted strategies- Measure improvements and refine if required- Communicate to next unit/ward>

Further Information

• Clinical Excellence Commission (CEC) Enhancing Project Spread and Sustainability –A Companion to the ‘Easy Guide to Clinical Practice Improvement’

• www.cec.health.nsw.gov.au/programs/clinical-practice

References1. Tam V, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE.

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173:510-5.

2. Dobrzanski S, Hammond I, Khan G, Holdsworth H. The nature of hospital prescribing errors. Br J Clin Govern 2002;7:187-93.

3. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424-9.

4. Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual 2005;20:95-8.

5. Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006;15:122-6.