Continuity of Medication Management Spreading Medication Reconciliation Improvements

Continuity of Medication Management Spreading Medication Reconciliation Improvements Hospital Presenter Month YYYY

Continuity is an Issue in Health Care • 10 -67% of medication histories contain at least one error 1 • Incomplete medication histories at the time of admission have been cited as the cause of at least 27% of prescribing errors in hospital 2 • The most common error is the omission of a regularly used medicine 3 • Around half of the medication errors that happen in hospital occur on admission or discharge 4 • 30% of these errors have the potential to cause harm 3, 5

Local Examples - Medication Errors <Insert summarised case notes> <Insert resulting effect on patient> <Insert consequence e. g. contributed to death> <Insert resulting effect on patient> <Insert consequence e. g. caused moderate to severe harm> <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 Insert group name Insert cause Insert cause Insert cause Insert effect Insert cause Insert cause Insert group name

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

References 1. 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.