Multidisciplined process redesign: A collaborative approach to system-wide electronic medication reconciliation improvement

Background

Medication errors and adverse drug events (ADEs) pose large threats to patient wellbeing and safety.   Medication errors are the most common errors occurring in hospitals.^1,2 Preventable ADEs are linked with 1 in 5 injuries or deaths.^3,4 Medication errors occur at key points of transition during the hospital stay.^4-6 At one institution, failure to reconcile medications at transition points accounted for 50% of all medication errors and 20% of ADEs.⁵ Medication errors and ADEs are harmful, but also costly to the patient and the healthcare system.⁷ Complete and accurate medication reconciliation is crucial for reducing medication errors and ADEs.^{4, 6-8}

Systematic electronic medication reconciliation processes have proven difficult and often burdensome to implement for healthcare institutions nationwide due to their complexity. The implementation effort has been so challenging that The Joint Commission revised its National Patient Safety Goals to reduce the requirements for medication reconciliation.^7,9 Improving medication reconciliation processes should be a system-wide patient safety goal collaboratively driven by hospital leadership and providers,and such efforts need to involve multiple disciplines applying simple, adoptable tools.^5,7,8,10

The collaborative performance improvement project at Trinity Health aimed to redesign the system-wide medication reconciliation processes using industry-leading practices. These practices would result in new standardized processes that, when used at every transition in care would help the organizations to be more patient-centric, reduce harm and improve safety measures. The project goals were to: (1) create standard electronic medication reconciliation processes, (2) clarify staff roles and responsibilities and assign accountability, (3) engage clinicians in the design and implementation of better processes, (4) provide replicable, easy-to-use tools, (5) implement a measurement and monitoring process and scorecard and (6) develop the change management, training, and education necessary for phased implementation system-wide.

Experience

Methods: Trinity Health created a Medication Reconciliation Collaborative, led by clinicians from hospitals system-wide and corporate leadership. The Collaborative sought to incorporate leading processes to best execute medication reconciliation and identify clinical accountability required to effectively complete medication reconciliation. Training and education were developed to support implementation of newly defined medication reconciliation processes and IT changes. A change leadership and communication plan was defined and a metrics dashboard developed to measure improvement at the local level and across the enterprise.

Results: Thirty-one of Trinity Health’s 47 hospitals participated in the Collaborative for 6 months from December 2010 to May 2011. Trinity Health has since improved its system-wide admission medication reconciliation completion rate by 35%, discharge medication reconciliation completion rate by 4% and overall composite medication reconciliation completion rate by 17% (composite medication reconciliation is the rate of patients for whom both admission and discharge medication reconciliation are completed (Table 1). Over the past 2 years Trinity Health has experienced a 5% reduction in ADEs however there were many other medication safety enhancements (ie, point-of-care medication administration, revision of medication ordering practices, standardization of high-risk medications, etc.) made across the system at the same time and it is not possible to attribute the ADE reduction to a single intervention.

Figure 1: Reconciliation trend table

Source: Trinity Health-Accenture Medication Reconciliation Study, 2012

Conclusion

Electronic medication reconciliation (EMR) is a complex and challenging task for healthcare providers nationwide. Through a clinician-led, collaborative and multi-disciplined approach, Trinity Health redesigned and implemented system-wide medication reconciliation processes, roles, and responsibilities. Collective and timely decision-making from system-wide front-line clinicians and organizational leadership were essential to the collaborative’s success. This clinician-driven approach has practicing clinicians and front-line staff from across the national system leading the development, design, and implementation of standardized, evidence-based clinical improvements. Many processes called for technology solutions that required EMR modifications. Consequently, adequate training, education, and reinforcement were, and continue to be, necessary for staff to implement the best practices given the current (EMR) technical capabilities and staff turnover.

Trinity Health hard-wired workflow changes in the EMR and implemented newly defined medication reconciliation processes across the enterprise. The program’s success was fueled by collective, timely decision-making from front-line clinicians. Clinical leaders worked with EMR architects to build technological solutions and optimize clinical work processes. The program found success through organizational leadership, simplified workflows, reduction of barriers, adequate training, and staff reinforcement to implement best practices-efforts that will result in improved patient safety. 

Dr Ripley is director of pharmacy operations and medication cycle improvement, Trinity Health. Ms Vieira is with Accenture Clinical Services.

References

1.    Bates DW, Spell N, Cullen, DJ et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997 Jan 22-29; 277(4):307–311.

2.    Agency for Healthcare Research and Quality (AHRQ). Translating research into practice: Reducing errors in healthcare 2002. Accessed Aug 18, 2012. http://archive.ahrq.gov/qual/errors.htm.

3.    Leape LL, Brennan TA, 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 Feb 7; 324:377–384.

4.    Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005 Feb 28;165:424-429.

5.    Rozich JD, Howard RJ, Justeson JM, et al. Standardization as a mechanism to improve safety in health care. Joint Com J Quality and Safety. 2004 Jan; 30(1):5-14.

6.    Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004 Aug 15;61:1689–1695.

7.    Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: A consensus statement on key principles and necessary first steps. J Hosp Med. 2010 Oct; 5(8): 477-85.

8.    Pronovost P, Weast B, Schwarz M, et al. Medication reconciliation: A practical tool to reduce the risk of medication errors. J Critical Care. 2003 Dec; 18(4):201-205.

9.   Geller KH, Guzman JL. National patient safety goals. JCAHO. 2005.

10. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006 Mar 30;166:565-571.