Lessons from the High 5s Project - Australian Commission on Safety

Lessons from the
High 5s Project
Margaret Duguid
Former Pharmaceutical Advisor
Helen Stark
Senior Project Officer
14 November 2014
Background and goals
Project methodology
Lessons learned
Australian results
National Safety and Quality Standard 4 –
Medication Safety
WHO High 5s Project
• Established by WHO in 2007
• International collaborative WHO, Joint
Commission International and 9 countries
• Australia, Canada, Germany, France, The
Netherlands, Singapore, Trinidad &
Tobago, UK, USA
• Funded WHO, AHRQ, Commonwealth
• 5 year project
WHO High 5s Project
• Determine feasibility of implementing
Standard Operating Protocols (SOPs) in
no. countries, healthcare environments
• Assess impact on patient safety
Slide 1 of 14
WHO High 5s Project
Standard Operating Protocols (SOPs)
1. Correct procedure at correct body
2. Medication accuracy at transitions
of care (medication reconciliation)
3. Concentrated injectable medicines
Project oversight
• High 5s Steering Group
• Face to face meetings – 2 x year
• Monthly teleconferences
• High 5s website
• E- bulletin for High 5s hospitals
• Webinars
• International hospital meeting
• Medication Continuity Expert Advisory Group
Medication reconciliation SOP
Medication errors at transfer of care – the
Discharge orders
Medication orders
30 – 70% patients had discrepancies
Between history and admission orders3
41% patients had ≥ 1
23% omissions5
Readmission 2.3 x more
likely if ≥ 1 med omitted6
Admission Histories
10 -67% contain
Up 1/3 errors PADE2
Internal transfer
62% patients had ≥ 1
unintentional discrepancy
36% PADE4
1. Tam VC, Knowles SR et al, CMAJ 2005
2. Cornish PL, Knowles SR, Archives Int Med 2005 3NICE NPSA Tech Bulletin medication reconciliation 2007 . 4. Lee J et al Annals
Pharmacotherapy 2010
5.Wong J et al Annals Pharmaco 2009 6.Stowasser, J Pharm Pract Res 2002
Medication reconciliation – the solution
Formalised medication reconciliation at admission,
transfer and discharge reduces medication
discrepancies (errors)
by 50 – 94% 1-4
Vira T, Colquhoun M,et al. Qual Saf Health Care 2006;15:122-6.
Pronovost P, Weast B, et al. J Crit Care 2003;18:201-5.
Santell JP. Jt Comm J Qual Patient Saf 2006;32:225-9.
Rozich JD, Resar RK. J Clin Outcomes Manage 2001;8:27-34
Medication reconciliation
“Medication reconciliation is the formal process in
which health care professionals partner with
patients to ensure accurate and complete
medication information transfer at interfaces of
Medication reconciliation SOP
• Formal, structured process
• Staff trained
• Multidisciplinary
– Doctors, nurses, pharmacists, pharmacy technicians
Partnership with patients, families, carers
Integrated into existing processes of care
Within 24 hours of admission
Phase 1
– On admission for patients ≥ 65 years of age admitted
through emergency department to a hospital ward
Medication reconciliation process
• Obtain a best possible medication history (BPMH)
Step 1
• Confirm the accuracy of the history
Step 2
• Reconcile the BPMH with prescribed medicines
Step 3
•Supply accurate medicines information
Step 4
•Obtain a best possible medication history (BPMH)
Step 1
• Interview patients and/or carers ( if possible)
• Systematic approach
• Compile an accurate and comprehensive list
• Current medicines patient taking
– prescription, OTC, complementary medicines
– Recent changes, medicines ceased
Step 2
•Confirm accuracy of history
Verify with one or more sources
• Carer or family
• Medicine containers (including blister packs)
• Medicines lists (patients)
• GP lists, records
• Community pharmacy records
• Electronic/paper health records, discharge
• Medication charts from other facilities e.g.
nursing home
Document in one place in patient record
Use to :
• Document BPMH
• Document sources of
• Reconcile history
with prescribed
• Document issues,
discrepancies and
One source of truth
Keep with NIMC
for easy access
• Reconcile BPMH with prescribed medicines
Step 3
•Compare with medicines ordered
•Resolve discrepancies with prescriber, document changes
•Supply accurate medicines information
Step 4
• The person taking over the patient’s care is supplied with an
accurate and complete (reconciled) list of the patient’s medicines
and explanation of any changes.
• Internal transfer of care (e.g ICU transfers)
• Discharge
• Care provider
• Patient and carer
Project methodology
1. Complete AHRQ patient safety culture survey
2. Implement Medication Reconciliation SOP
Using QI methodology
3. Evaluation plan
• Implementation experience survey (6 monthly)
• Performance measures
– Rate and quality of medication
• Analysis of SOP related adverse events
• In-depth interviews with 3 sites
– 5 sites in Australia
Project implementation in Australia
• Commenced January 2010 - 18 health
• 2 x 2 day workshops 2010
• 2 x 1 day workshops in 2011
• Video conference 2013
• Teleconferences - monthly then 2nd monthly
• Webinars, email newsletter
• All materials posted on High 5s website
• Support from senior project officer
High 5s workshop 2011
Peoples choice
Poster award winners
High 5s hospitals
Implementation resources
Medication reconciliation resources
MATCH UP Medicines
•. . .
Medication management plan
+ implementation resources
Medication reconciliation resources
“Get it right. Taking a best possible medication history ”
CD and You tube channel
www. Safteyandquality.gov.au
2. Online learning module
Improving quality and timeliness of
information on admission
Engaging with consumers
•“Mistakes can happen with
your medicines”
•How to prevent them
•Have a medicines list
AUSTRALIA: Australian Commission on Safety and Quality in Healthcare
with patient
Implementation Strategy
Oversight of implementation
Project work plan
Risk assessment of proposed process
Pilot testing
Spread methodology
Communication plan
Evaluation Strategy
Maintenance and improvement
Reasons for withdrawal
6 Australian health services withdrew
Change in priorities
Lack of resources for evaluation, independent observer
Lack of resources for MR process , evaluation
Concern re MR taking focus away from medication review
Lack of perceived benefit
Lessons (International)
• Full implementation was challenging
• Reliant on pharmacists for success
• Additional pharmacists needed for:
• More timely BPMH, medication reconciliation
• Coverage for after hours, weekends and
• Coverage of new areas , wards units
• Performance measurement essential
Lessons – Challenges and barriers
Lack of
- Training
Lack of
Technology to
support Med
Lack of buy in
Senior staff
Barriers and
challenges to
Lack of human
resources for:
Med Recon
Data collection
Lessons – Benefits of SOP
Positive impact
Related activities
Patient care
discrepancies and
potential ADEs
benefits of the
Measurement data
used for business
case to gain
hospitals and
community care
Drivers for SOP implementation
• National guidelines and standards
• Accreditation requirements
• Access to community dispensing data
• Pharmacy technicians
What makes for effective and sustainable
medication reconciliation?
• Recognition as a patient safety priority
• Senior leadership support from the health
service executive and senior clinicians
• Interested and influential clinical champion(s)
• Resources to conduct medication reconciliation
and measure improvement
Effective and sustainable medication
reconciliation (cont’d)
• Ongoing training of clinical staff
• Policies and procedures on medication
• Integration of Med Rec into existing work flows,
electronic health records and clinical
information systems.
Further information on High 5s project
Medication Safety Standard
High 5s Project Resources
Medication safety standard
Australian Project
Margaret Duguid
Pharmaceutical Advisor
Helen Stark
Senior Project Officer
Importance of measurement
Evaluation Strategy
Evaluation Results
The Problem
Tam VC, Knowles SR, Cornish PL et al. Frequency, type and clinical importance of medication history
errors at admission to hospital: a systematic review. CMAJ, 2005; 173:510-515
The Problem
Recent Australian paper1
Multi-centre, prospective observational
study in 8 EDs
Patients taking more than one medicine
and a GP referral letter (median 6)
GP referral letters compared with BPMH
taken by ED pharmacist n=414 patients
1. Taylor S et al, Australian Family Physician Vol. 43, No. 10 Oct 2014
The Problem
87.2% patients had one or more
discrepancies between BPMH and
GP referral letter
Median no. of discrepancies was 3
Most common: omission of
regular medicine or inclusion of a
medicine patient no longer taking
62.1% of patients had one or more
discrepancies of moderate or high
Multi-component evaluation strategy
Measurement an integral component of the SOP
1. Performance measures
2. SOP implementation experience
3. Event Analysis
1. Performance Measures
Four years of data (June 2010 to June 2014)
Four measures (MR1 – 4)
10 hospitals contributing, staggered implementation
Project level – results show significant variation from
hospital to hospital and country to country
Present Australian data only
MR1: Percent of patients reconciled
within 24 hours of decision to admit
Measure hospital’s capacity to reach as many eligible patients as possible
Creation of BPMH, identification of discrepancies & communication to
prescriber within 24 hours
Eligible patients: 65 years and over admitted through ED to inpatient services
All eligible patients or random sample of 50 using approved sampling method
Monthly data collection
Entry into High 5s secure website, approved by Commission
Goal: 100%
MR1: Percent of patients reconciled
within 24 hours of decision to admit
MR1 ranged from
41.8% to 59.4% across
participating hospitals
with an average of
around 50.4%
Trend line stable
Key finding:
Reconciliation within 24
hours regarded as ideal
for patient safety but
difficult to achieve for
majority of hospitals
MR1: Percent of patients reconciled
within 24 hours of admission
Quality measures: MR 2,3,4
To verify quality of medication reconciliation process
Use independent observer to pick up outstanding medication discrepancies
Intentional vs unintentional, documented vs undocumented
Chart audit (n=30) from sample of 50 taken for MR1
Prospective or retrospective
Monthly then quarterly or six monthly if stable
Data verification & entry into High 5s website
Aim to reduce to a minimum
MR3 target of less than 0.3 per patient
MR4 no target specified
Quality measures: MR 2,3,4
Mean number of outstanding undocumented intentional
medication discrepancies per patient
Mean number of outstanding unintentional medication
discrepancies per patient
Percentage of patients with at least one outstanding
unintentional discrepancy
Measuring accuracy of the medication reconciliation process
Discrepancies that have “slipped through the cracks”
MR2 example: betablocker stopped by surgeon before surgery but not
documented anywhere
MR3 example: omission, commission, wrong medication, strength, dose or form
MR2 – mean undocumented intentional
discrepancies per patient
Prescriber made an intentional choice to add, change or discontinue a
medication but decision not clearly documented
Creates confusion, additional work and could lead to ADEs
MR3 – mean outstanding unintentional
discrepancies per patient
Where med rec is conducted,
hospitals achieved target of less than
of 0.3 outstanding unintentional
medication discrepancies per patient,
with trend towards zero over time for
several hospitals
MR4 – percent of patients with at least one
outstanding unintentional discrepancy
Limitations of MR1 - 4
Small sample size for MR 2 – 4
Only review med recs done within 24 hours
Definitional issues
• what to include as a discrepancy/MR2 vs MR3
• Inter-rater reliability issues
• Prospective vs retrospective data collection
Herbal medicines should be documented on BPMH however
omission considered to be intentional and discrepancy not counted
eg., MO didn’t order Ginseng but not documented
OTC medicines should be treated same as prescription meds
because prescriber needs to make decision about continuation or
non continuation eg aspirin
2. Implementation Experience Surveys
All hospitals completed survey every 6 months
Annual interviews conducted in 5 hospitals
Provided additional insight on hospitals’ experience
Reported benefits from SOP
Reduction in medication discrepancies and potential
medication errors
Standardisation of med rec processes across the hospital
Spreading from admission to discharge and improved
business processes at discharge
Embedding process into hospital work flow and routine data
collections - strong framework for hospitals to meet relevant
criteria in the Medication Safety Standard 4
Reported benefits from SOP
Improved teamwork & recognition of importance of med rec
among non-pharmacist clinicians and senior mgt
Improved communication with community health care providers
and patients
Opportunity to participate in international patient safety project
and associated benefits of sharing lessons learned nationally and
Access to Commission training materials and resources
Using High 5s data to obtain additional pharmacy staff for
medication reconciliation after hours/weekends
Reported benefits from SOP
Multi-facetted High 5s evaluation strategy provided hospitals with
in-depth understanding of the medication reconciliation service
Performance measures useful for:
• Tracking improvement, providing feedback to staff, mgt
• Identifying gaps in practice, training requirements
• Developing business case for resources
• MR 1 and MR3 - most useful
• Majority will continue to evaluate med rec with some moving
focus to discharge
• Med rec now part of “usual care”
“The High 5s project has engendered
pharmacists and medical staff with a greater
understanding of the value of preventing adverse
consequences from medication discrepancies and
clear documentation of their intentions. Although
we believed that we already performed medication
reconciliation to a high standard, the audit process
has allowed us to become more consistent across
our service”
(metropolitan hospital)
Challenges – staff resources /staff resistance
Not my
No. patients receiving medication
reconciliation is closely tied to available
clinical pharmacist resources
Medical and nursing staff often report “not
their job”
Some nursing staff feel they lack the
necessary pharmaceutical knowledge to
perform this task
Hospitals report some improvement in
teamwork over project
Real change requires education at under
graduate level
Challenges – lack of staff
No. of clinical pharmacists varies markedly by hospital and
Private hospitals - less clinical pharmacists resulting in lower
rates and reduced ability to spread med rec across the
Education of large numbers of staff – required significant initial
and ongoing commitment & resourcing (under estimated upfront)
Hospitals were required to re-allocate clinical pharmacy staff
from other tasks to conduct med rec and/or for project evaluation
and education
How many hours per week does the hospital
provide a medication reconciliation service?
40 hours or less per week
41 - 50 hours per week
70+ hours per week
number of hospitals
Challenges – lack of electronic systems
Lack of integration of med rec (paper) with eMM systems
Some sites had a new eMM system in ED introd. during
“Medication reconciliation is conducted in all inpatient
areas. Improving timely rates of medication
reconciliation on all eligible patients within 24 hours
will only be possible when electronic documentation of
medication reconciliation is available and this tool can
interact with current medicine management systems”.
(large metropolitan teaching hospital)
Future Plans
Plans to implement electronic systems for medication reconciliation
Yes, within the next 12 months
Don't know
Yes, within the next 2 years
Yes, within the next 5 years
Yes, after 5 years
number of hospitals
3. Event Analysis (EAs)
3rd evaluation component
Hospitals required to actively seek and investigate events that
should have been prevented by the SOP
EA – systematic analysis of the facts & contributing factors leading
to an patient safety incident (“mini RCA”)
Link to SOP implementation
Event Analysis (EAs)
17 EAs reported by 6 hospitals
No serious ADEs reported over the course of the project
Most events due to a failure to undertake med rec in timely
Major contrib. factors were lack of teamwork, education &
training and poor communication
Those that did EA learnt from analysis of actual ADEs
 Case studies used for education of other clinicians
 Improved processes
 Business case for more resources
EA Case Study
• A 73 year old Parkinson’s patient was admitted for
investigation and rehabilitation after a fall
The patient had his Webster pack with him which had
clear dose times and directions to give Parkinson’s
medicines at 6am, 10am, 2pm, 6pm and 10pm however
the MO ordered medicines for the first four dose times
only omitting all the 10pm doses
The omitted medicines included: levodopa/carbidopa
CR200/50mg, mirtazapine 30mg, pregabalin 25mg and
quetiapine 50mg
• There was no clinical pharmacist on the ward because
the usual pharmacist was on leave with no replacement
EA Case Study
• The patient was not given doses of his usual 10pm
medications for the next two days
• It was recorded throughout the patient’s notes that the
patient was having multiple mobility issues. The nurse
recorded that this could have been part of his usual
symptoms or alternatively, a worsening of his Parkinson’s
symptoms i.e. “Parkinson’s tremor gradually worsening
throughout shift”
EA Case Study
• The treating MO asked a clinical pharmacist on a different ward to see the
patient on the third day because of worsening mobility
The pharmacist interviewed the patient but he was a poor historian and
was unable to give an accurate medication history
The pharmacist then spoke to the patient’s wife (carer) to establish the
correct medicines as well as using the Webster Pack brought into the
hospital as the 2nd source for the BPMH
• After seeing the patient and taking the BPMH the medication errors were
noted and the Doctor was asked to amend the medication orders
The doctor re-charted all of the omitted medicines. The patient’s
symptoms gradually abated and he recovered fully the next day
Learning from EA
The process of taking a BPMH and admission reconciliation was
introduced to JMOs at orientation
The hospital used case study to educate JMOs on importance of
using multiple sources to confirm the medication history, including
blister packs
Business case for additional clinical pharmacist
“…Involving the medical and nursing staff as well as the Quality
Manager in the event analysis process has resulted in new
policies and actions to prevent near misses. The teamwork
involved in the project has resulted in greater cooperation
between clinicians which in turn has led to less medication errors
(eg omission errors)….”
(metropolitan hospital)
Commission Resources
SOP & Implementation Guide
MMP, user guide and flash presentation
MATCH Up medicines brochures & posters
BPMH Video and online learning module
Consumer wallet
Feasible to implement High 5s Medication
Reconciliation SOP in different countries and cultures
Requires some local and national adaptation
Improves patient safety
Complex process
Challenging to implement, requires careful planning
Measurement is critical to successful implementation
Now let’s hear from the hospitals
•High 5s hospitals
•Alfred Health Vic
•Armadale Health Service WA
•Epworth Healthcare Richmond Vic
•Greater Southern AHS NSW
•Logan Hospital, Qld
•Mater Health Services Qld
•Noosa Hospital Qld
Medication Continuity Expert
Advisory Group
•North West Regional Hospital TAS
•Prince of Wales Hospital NSW
•Redland Hospital NSW
•Rockingham Hospital WA
•Royal North Shore Hospital NSW
•The Wesley Hospital Qld
Australian Commission on Safety and
Quality in Health Care
E: [email protected]

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