Beth Averbeck, MD, Associate Medical Director, Care Improvement

Burke Kealey, MD, Assistant Medical Director for Hospital Services

Jackie Huebsch, PhD, RN, CNP, CHF Clinic Provider

Judy Carpenter, RN, CHF Clinic Nurse

Tim Lindquist, RN, Senior Quality Coordinator

Maribet McCarty, PhD, RN, Data Analyst

• By July 2006, all patients discharged from Regions Hospital telemetry units with any diagnosis of congestive heart failure (CHF) will have an accurate medication list in the electronic medical record (EMR), as verified at follow-up appointment in the CHF clinic.

• Ensure the accuracy of the EMR medication list and the patient’s understanding of medications in the week following discharge.

• Composite and all-or-nothing measures incorporating:
  • Medication list to clinic on discharge
  • Medications reconciled prior to visit
  • Medications reconciled at first outpatient visit
  • Right medication, dose, frequency in EMR at visit
  • Right medication, dose, frequency in EMR at discharge

• ADE-related readmissions within 30 days for CHF clinic patients

Our tests of change focused on informing the clinic of the patient’s discharge and medication list and methods for contacting patients to reconcile medications. Our key changes were:

• Tested and abandoned different mechanisms for staff to fax the discharge medication list to clinic.
• Tested and implemented twice weekly email from unit coordinator to CHF clinic regarding discharges.
• Tested and implemented clinic RN phone reconciliation of medications.
• Tested and implemented all contact information (beepers and pagers) on discharge sheet.
• Spread, tested, and implemented the inclusion of discharge medication follow-up to calls already being made by staff nurses to patients 72 hours post hospitalization to all patients, condition neutral, on a medical/surgical unit.

Summary of Results

This project has resulted in improved safety for patients through identification and mitigation of medication errors. 

• We focused efforts on transitions in care where patients are vulnerable.
• The operational participants found this work valuable and have adopted for all new patients. 
• This work was time-neutral and there was no added cost or FTE. 
• Six out of 79 patients had identified clinically significant medications that were not reconciled and this work was able to potentially mitigate a readmission for these patients.

Lessons Learned

• Engage operational leaders and front-line staff early.
• Start with smaller, defined population, develop and redesign processes for reliability before spreading to next segment — small segment allowed for multiple tests of change in a very short time frame.
• Process needs to be position (not person) dependent.
• Maximize the skill sets of all members of the care team. This work was done by an RN to free up the time of a NP which allowed her more time to discuss care goals with patients.
• Coordinate changes with, and take advantage of, other organizational initiatives. Staff were receptive to implementation when we linked this work with other work already being done (e.g., discharge phone calls).
• Keep a list of successes: these ‘stories’ are as important as the data.

Next Steps

• Formed expert panel to guide spread to other clinics and patient populations. 
• Develop guidelines that match medication reconciliation intervention to patient vulnerability. For example, do we need to call patients at home if they are only taking a multivitamin?  Should we reserve phone calls for patients taking 5 or more medications, or for those aged over 65 years?
• Spread discharge calls to other nursing units.
• Identify role of pharmacists in medication reconciliation.
• Design other clinical processes using reliability design concepts.

A team of IHI content experts has reviewed this report and determined that it is a compelling example of current results from organizations working with IHI.

09/29/2006