Creating a culture of patient safety is a significant priority at Niagara Health System. One of the ways we aim to improve patient safety is through our medication reconciliation (MedRec) initiatives.
By using a systematic and organization-wide approach, we have significantly improved the number of patients who have their medication reconciled on admission from 12.6% to 38% within a year. In this post, I’m pleased to share the journey our hospital took, the lessons we’ve learned and our MedRec goals for the future.
From left to right: Susan Cubelic, Director of Pharmacy, Andrea Forgione, MedRec Pharmacist
Organizational commitment to MedRec
One of the most important ways we move our MedRec improvements forward is through our organizational commitment to this initiative. MedRec is embedded in our strategic plan and yearly Quality Improvement Plan (QIP) submitted to Health Quality Ontario. We report progress to our executive team, the Board Standing Committee, Medical Advisory Committee and Quality Committee on a regular basis.
Our organizational commitment to MedRec has created the mandate needed to ensure we consistently focus on this initiative in our hospital.
From a staff perspective, we have assembled an interdisciplinary MedRec Steering Committee led by one of our physicians. The Committee includes the MedRec physician lead, MedRec pharmacist, Director of Information Services, Director of Pharmacy, Quality, and Patient Safety Manager, Practice Lead. This type of leadership, along with physician peer-to-peer support, helps to ensure that MedRec programs roll out smoothly and in a sustainable manner across our patient care units.Finding the right people to champion this work is very important to get staff members on board.
Our organization has also provided financial commitment to MedRec by allocating hospital budget funds to place pharmacy technicians in the emergency department (ED), alongside the pharmacists. The pharmacy technicians complete the majority of Best Possible Medication Histories (BPMHs) for patients who will be admitted to hospital and consult with our pharmacists when working with more complex patients. Our pharmacists and pharmacy technicians have access to real-time MedRec dashboards to see which patients don’t have a BPMH completed so that they can follow up with them in a timely manner.
To provide a standardized approach to BPMH documentation, we have developed a two-day in-house BPMH certification course, which includes e-learning modules, one-on-one instruction, and observations with our MedRec pharmacist. This course is available to our pharmacy technicians. All educational resources to support the MedRec process are available on our organization’s intranet.
Regular and continuous quality audits are also conducted by a dedicated MedRec Pharmacist Lead. Her role is to review MedRec metrics and quality and provide feedback to the various MedRec programs across the organization. The audits provide excellent learning opportunities from a practice management perspective. The pharmacist’s role also includes recognizing programs that achieve their targets, overseeing the BPMH certification process, and providing education and support to our nurses and physicians. This focused attention to MedRec has certainly helped to keep this work moving forward.
Finally, in 2016, Niagara Health System was the only
Canadian hospital selected to be part of the Multicenter Medication
Reconciliation Quality Improvement Study -
MARQUIS. The goals of this study are to
operationalize best practices for inpatient MedRec and test their effect on
potentially harmful medication discrepancies. Our organizational commitment and
existing MedRec improvements helped us be successful in our MARQUIS
Engaging patients and community pharmacists
In addition to organizational leadership, engaging patients and community pharmacists is an important part of our MedRec initiative.To encourage patients to come prepared to the hospital with their medications, we have developed a communication strategy which includes sharing key messages on our website, twitter feed, and president’s weekly blog, and posting information in the ED. Patients are also encouraged to use our fillable medication brochure called Your Medications Matter. Intermittently, we work with local cable television shows and radio stations to raise awareness as well.
MedRec is equally important on hospital admission and discharge. That's why we have engaged with community pharmacists to improve awareness of Niagara Health's MedRec process.
We reached out to community pharmacists and technicians through the network of Niagara community pharmacies to invite them to in-person education session. The session reviewed how BPMHs are done in hospital and by whom, the requirements for MedRec at transition points within hospital facilities, between hospital and home, or elsewhere, and what information they can expect to receive upon patient discharge.
During the session, we included time for open discussion and feedback. The feedback was excellent. We have made improvements to our process to ensure safer patient transitions and support the needs of our community pharmacies.Currently, we work with one key community pharmacist to further strengthen this partnership.
When we started the journey to improve MedRec at Niagara
Health, we assumed that it would be a simple implementation across our hospital
departments. Every patient care unit asks and documents information about
medication use in some way. But the differences in the consistency and
completeness of this information created challenges.
Due to this complexity, we decided to start small with our
mental health unit to test out a MedRec program. In this unit, the physician
and nursing staff tend to stay consistent, which allowed us to test our change
ideas without a lot of staff changeover. This helped us gather feedback and
lessons learned in a more efficient manner before we felt confident to roll out
a MedRec program in more complex units.
We use the same BPMH form to standardize the process across
patient units, but it’s important to have some flexibility to tailor the form
when needed. For example, there are some small differences in the discharge
prescription form for our obstetric and pediatric units due to the differences
in the patient population, but overall, the essence of the process is the same.
This is how we have incorporated feedback from each unit into the overall
Another significant challenge we faced was about gathering
initial metrics about MedRec on admission. Manually reviewing a small sample of
charts is very labour intensive and may not be representative. To address this
challenge, our IT department created a report to gather reliable real-time data
as to which patients have had MedRec documents completed.
One of greatest achievements has been to change the culture
around MedRec from being the pharmacists’ responsibility to being everyone’s
responsibility including physicians, nurses, nurse practitioners and pharmacy
This collective commitment took time and required ongoing
engagement and encouragement with stakeholders, and support from our leadership
Goals for the future
Now that MedRec on admission is implemented hospital-wide, our goal for this upcoming year is to increase the number of patients who have their medication documented and reconciled within 24 hours of admission from 38% to 90%.
We believe this target is attainable based on the sustained improvements we have been able to achieve until now, and the systematic way we have been rolling out MedRec to our programs.We will also be working towards improving the quality of MedRec on admission and discharge.
Visit Quorum’s Indicators & Change Ideas page for more information on medication reconciliation at discharge.
Do you have questions or comments for Susan about her MedRec experiences? Add your comments below or reach out to Susan on Quorum.