Researching the Impact of Medication Reconciliation Technicians (MRTs) in the ED

Introduction One of the most significant issues facing patient safety is medical errors. It has been estimated that as many as 98,000 deaths per year are a result of these mistakes with at least one third being medication inaccuracies (Henneman, 2007). 30% of these medication errors are due to prescribing errors related with incomplete medication histories upon admission (Sanchez, 2014). The implementation of an effective medication reconciliation program upon admission has been shown to significantly decrease these discrepancies and thus decrease errors and produce improved patient outcomes. Since 2006 the joint commission has showed the importance of Medication Reconciliation by making it a national patient safety goal. According to the National Patient Safety Goals for 2014 The Joint commission describes Medication Reconciliation as a system intended to “identify and resolve discrepancies—it is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications.” (National Patient Safety Goals, 2014) In general the purpose of medication reconciliation is to provide the best possible medication history for a patient and compare it to the prescribed medications from medical clinicians throughout various transitions of health care. Background In July 2012 a team from the Pharmacy Department discovered from self-reports and other professional sources that 98% of patient medication information at LVHN contained errors and 47% of LVHN med rec contained at least one error. After sending a survey to physicians and nurses to measure their approval of the current system of acquiring medication history, 70% responded with dissatisfaction. In order to improve their adherence to The Joint Commission Med Rec National Safety Goal a quality improvement group comprised of various departments was assembled in August 2012. It was concluded that the implementation of new Medication Reconciliation program carried out by medication reconciliation technicians ( MRTs) in the Emergency Department would be a viable solution to prevent medical errors and acquire more accurate medication history. The task of the MRT would be to acquire the best possible medication history prior to physician examination through a personal interview with the patient and a thorough investigation of various sources of patient medication such as pharmacies, nursing homes, medical records, and previous hospital discharge notes. Following this assembly, a 10 month pilot MRT program was initiated in October and medical personnel within the ED were explained their roles in the new workflow. After 10 months the program decreased the Medication Reconciliation discrepancy rate from 47.5 to 2.5 % by January 2013. This rate averaged 3.6% over the next 10 months, and reduced to 0.9 by August 2013, this can be seen in figure A. The success in the MRT pilot program is ultimately what has influenced this study. The future vision is to receive additional funding to increase the number of MRTs within LVHN and thus provide improved patient outcomes. Objective The purpose of this study is to measure the impact of Medication Reconciliation technicians (MRTs) in the Emergency Department in improving the health care continuum and to examine the effect of faulty medication reconciliation in causing medication error events. Methodology In order to quantify the percentage of errors at Lehigh Valley Health Network (LVHN) that were related to Medication reconciliation, medication events reported by medical personnel from October 2013 to June 2014 were reviewed. The Medication events were classified on a harm scale from A - I. A meaning no harm to the Patient and I meaning a medication event that resulted in an adverse drug event (ADE) that led to a patient death. Data from the LVHN Hospital data warehouse extracted from electronic medical records from care management was analyzed to measure the impact of MRTs on the average length of stay and variable cost. This data consisted of metrics concerning average length of patient hospital stay when MRTs completed the medication reconciliation compared to the average length of stay when medication reconciliation was completed by LVHN hospital staff such as Physicians, Physicians assistants and nurses. All patients were divided into different MSDRG code groups, diagnosis codes that state the reason for patient admission. The MRT group contained 827 patients within MSDRG codes of 20 patients or more. The LVHN group consisted of 11,793 patients and was comprised of MSDRG codes with 250 patients or more. Patients with length of stays of three days or less or 10 days or more were removed from the data samples. These patients were considered outliers to the analysis. Results Of the 1546 Medical events that were reviewed from October 2013 to June 2014 12.8% percent were due to errors in Medication Reconciliation. This percentage affected 198 patients. These errors ultimately caused medical personnel such as nurses and physicians to commit medication errors such as commission, omission, incorrect patient, incorrect dose, incorrect route and contraindication. A subset analysis of 117 of these events shows the following: 41% reached the patient with no harm and were classified as a C level error. 42% were classified as A, B1 and B2 errors that did not reach the patient and were caught by medical staff. 2.5% were classified as E errors causing significant patient harm requiring intervention. 11% contained no level of classification. After calculating the differences in average length of stay (ALOS) between 21 different MSDRG codes between the MRT group and the LVHN group a decrease in patient LOS stay was shown in the medication reconciliation done by the MRTs. The total amount of time saved by the MRTs across all MSDRGs for all patients was 170 days. This total was calculated by multiplying the ALOS savings by the inpatient volume for each MSDRG category then adding the products from each category. The average amount of time saved per patient within each MSDRG code was 0.21 days which translates to approximately 5 hours. The time saved per ranged from 0.01 days to 0.65 days throughout the different codes. Discussion Other studies have shown that medication reconciliation makes up a large portion of medication errors. Some have estimated that erroneous medication reconciliation could account for as much as 46% of medication errors and 20% of ADEs (Sheeler, 2007). Though only 2.5% of the medication events were considered adverse drug events (ADEs) and caused considerable harm to the patient, estimates from the department of finance at LVHN calculated an average cost of $1171 per event and totals to an average of $137,007 for all 117 events. The fact that these patients were not treated by MRTs further shows the effectiveness of this Medication Reconciliation program in avoiding errors. When this process is done correctly upon a patient’s admission into the hospital, future discrepancies are less likely (Shojania, Fernandes, 2012, p. 45). Some possible factors responsible for inaccurate medication reconciliation in the emergency department include: lack of time to perform complete medication reconciliation due to emergency situations, existing biases by health care providers against acquiring a complete medication list (Shojania, Fernandes, 2012, p. 44) (Cohen, 2009), and failure to investigate over the counter drugs, herbal supplements, nutritional products, vitamins, and analgesics that are often overlooked in a patient history and could potentially interact with drugs given during a patient’s hospital stay (Cohen, 2009). The differences in LOS between the MRTs and LVHN staff are noteworthy. The department of Finance at LVHN estimated an average cost of $500 per day to treat a patient. When this value is multiplied by the total amount of days saved the result is a savings in excess of $36,000. Other studies confirming the direct impact of Pharmacy technicians in reducing the LOS by performing medication reconciliation were not found. However studies were found showing a correlation between discrepancies in medication lists and LOS. When discrepancies increased, the length of stay increased (Sheeler, 2007). Limitations The duration of this study lasted for two months and therefore did not allow time for all variables that could also contribute to a decrease in average length of stay to be examined. In addition there have been limited studies on how medication reconciliation performed by pharmacy technicians decreases the ALOS. Moreover the limited time frame of this study and inaccessibility to all available data prevented the opportunity to show the statistical significance of the difference between average lengths of stay between both groups. Conclusion Overall this study helped to show the importance of accurate medication reconciliation in health care and the impact that Medication Reconciliation Technicians have on reducing medical errors, decreasing average length of patient stay, and lowering patient care costs. As patients age and require additional medications this process will continually be a relevant practice in order to provide excellent patient safety improved patient outcomes. References Cohen, V. (2009). Target Medication Reconciliation in the Emergency Department. Safe and Effective medication Use in the Emergency Department Henneman, E. A, Caglar, S, & Smithline, H. A. Emergency Department Medication Lists Are not Accurate. academic emergency medicine, 40, S62-S62. National Patient Safety Goals Effective January 1, 2014. (2014, January 1). . Retrieved July 19, 2014, from http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf Sanchez, S. H, Sethi, S. S, Santos, S. L, & Boockvar, K. (2014). Implementing medication reconciliation from the planner\u27s perspective: a qualitative study. BMC health services research, 14(1), 290. Sheeler, R, & Varkey, P. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. American Journal of Health-System Pharmacy, 64, 850-854. Shojania, K, & Fernandes, O. Medication Reconciliation in the Hospital: What, Why, Where, When, Who and How?. Healthcare Quarterly, 15, 42-49 (Figure A) The spike in discrepancies during August ’13 was potentially due to 2 new FTE being trained at the Cedar Crest location. Med Rec Unintended Discrepancies by Month for LVH-CC (Data from 7/01/13 to 5/31/14) Date Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Discrepancies 2 5 4 1 3 2 3 1 2 Discrepancy % 3% 8% 0% 2% 1% 0% 2% 1% 1% 0% 1% Monthly Target 3% 3% 3% 3% 2% 2% 2% 1% 1% 0% 0% Total Med Rec Orders 80 61 141 175 86 132 138 152 226 251 329 (Figure B) Differences in Average Length of Stay between MRTs and LVHN (Data from April 2013-May 2014) MRT MSDRG INP MRT Volume ALOS Network Volume ALOS ALOS Savings 292 heart failure & shock w cc 73 4.47 940 4.50 -0.03 378 g.i. hemorrhage w cc 71 4.25 605 4.26 -0.01 392 esophagitis, gastroent & misc digest disorders w/o mcc 71 3.48 1,568 3.50 -0.02 871 septicemia or severe sepsis w/o mv 96+ hours w mcc 57 6.05 1,076 6.20 -0.15 191 chronic obstructive pulmonary disease w cc 54 3.99 511 4.06 -0.07 603 cellulitis w/o mcc 52 3.27 891 3.57 -0.30 683 renal failure w cc 47 3.73 615 4.28 -0.55 194 simple pneumonia & pleurisy w cc 47 4.22 596 4.26 -0.04 312 syncope & collapse 38 2.73 466 2.88 -0.15 690 kidney & urinary tract infections w/o mcc 36 3.59 585 3.90 -0.31 291 heart failure & shock w mcc 35 6.03 454 6.68 -0.65 872 septicemia or severe sepsis w/o mv 96+ hours w/o mcc 34 3.99 610 4.57 -0.58 193 simple pneumonia & pleurisy w mcc 32 5.07 332 5.50 -0.43 065 intracranial hemorrhage or cerebral infarction w cc 31 4.13 428 4.25 -0.12 948 signs & symptoms w/o mcc 28 3.37 274 3.80 -0.42 190 chronic obstructive pulmonary disease w mcc 28 3.90 297 4.20 -0.30 176 pulmonary embolism w/o mcc 26 3.51 310 3.66 -0.15 641 misc disorder of nutrition, metabolism, and fluids & electrolytes /wo mcc 24 3.20 393 3.45 -0.25 309 cardiac arrhythmia & conduction disorders w cc 22 3.12 448 3.19 -0.07 202 bronchitis & asthma w cc/mcc 21 3.85 394 3.93 -0.08 Total 827 11,793