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Assessing and improving medication reconciliation in adult cystic fibrosis care

Daniel Cortes, RPh BScPhm

Adult Cystic Fibrosis Program, Division of Respirology and the Pharmacy Department, St. Michaels Hospital
"At St. Michaels Hospital, obtaining a paper-based BPMH is a
responsibility shared amongst doctors (MDs), nurse practitioners
(NPs), nurses (RNs), and pharmacists (RPhs) and is to be
initiated by the clinician who is first point of contact
"Reconciliation is done by the MD or RPh
"Med Rec compliance is measured by the completion of a BPMH
that is documented on a Pre-admission (Home) Medication List
and Reconciliation Form (PMLRF)
Figure 2: CF Med Rec Process Map
Figure 5: RPh-provided Inpatient CF Med Rec Sustainability score
Inpatient CF Med Rec Pilot (March 8 - April 5)
PMLRF completed
(out of 24 patients)
% Med Rec
Avg. # medication
discrepancies / patient
24 100 3.33 (0-14)
Contact Information
"Share ongoing progress with CF team at already established
monthly CF-Quality Improvement meetings
"Monitor sustainability periodically and explore new change
concepts to address low scoring sustainability dimensions
"Spread initiative to all inpatient respirology patients
"Continue prioritizing RPh administrative, operational, and
clinical duties and explore pharmacy student integration
"Document medication discrepancies and clinical significance
electronically (Siemens Pharmacy database) to enable ongoing
outcome measurement
"Promote Med Rec as a component of medication therapy
management (MTM)
Daniel Cortes E-mail: cortesd@smh.ca
Figure 1: Inpatient Respirology Med Rec compliance, St. Michaels
"Inpatient respirology (6B) Med Rec - ~21% compliance
"Any and all CF team members communicate medication
di screpanci es to MDs di rectl y (urgent) and/or duri ng
interprofessional Kardex rounds (non-urgent)
Accreditation Canada, the Canadian Institute for Health Information, the Canadian Safety
Institute, and the Institute for Safe Medication Practices Canada. (2012). Medication
Reconciliation in Canada: Raising the Bar - Progress to date and the course ahead. Ottawa, ON:
Accrediation Canada.
Sawicki GS, Tiddens H. Managing treatment complexity in cystic fibrosis: challenges and
opportunities. Pediatric Pulmonology 2012 June; 47(6): 523-33.
Special thanks to Sabrina Chan, Charmaine Mothersill, Joyce Fenuta, and Janice Wells for their
guidance and assistance in this project.
Thank you to the St. Michaels Hospital Foundation and their support through the Quality
Innovation Fund.
"To achieve >60% Med Rec for hospitalized CF patients
between March 8th to April 5th, 2013

"Medi cati on Reconci l i ati on (Med Rec) i s a f ormal ,
interprofessional process requiring a systematic, comprehensive
review of a patients medications to ensure accurate and
comprehensive information is provided across transitions in care
"The process begins with a Best Possible Medication History
(BPMH) obtained by a systematic process, reviewing at least two
sources of information (i.e., patient and community pharmacy)
"Unintentional medication discrepancies / errors during transitions
in care are common and have the potential to cause harm
"Adult cystic fibrosis (CF) care can involve high treatment burden,
complex medication regimens, and frequent transitions between
ambulatory and hospital care
"Medication reconciliation in adult CF care is challenging
"Ambulatory and inpatient CF Med Rec with 100% compliance
"CF Med Rec is a standardized process minimizing medication
"Med Rec process integrated with identification and documentation
of medication discrepancies
"Locally developed quality improvement approach can lead to
Med Rec adherence
"Bundling medication discrepancy documentation and Med Rec
provides immediate feedback regarding clinical importance
"Literature search, observations, patient/clinician feedback identified:
Numerous CF medications, time-consuming medication histories
It is unknown if admission medication discrepancies occur in the
adult CF population and if they are clinically significant
CF ambulatory Med Rec process uses a paper form intended for
the CF clinic and the Toronto CF Database, and is not integrated
into an the current inpatient Med Rec process
Other CF team members play a role (i.e., dietitian, respiratory
therapist, physiotherapy, etc.)
Quality of BPMH / Med Rec more important than compliance

"Process mapping: February 2013
Ambulatory CF Med Rec process provides list for the admitting
MD to reconcile, assuming no changes since last clinic visit
PMLRF not routinely completed by MD or RPh due to
transcription redundancy
RN, RPh and other team members have an existing process to
relay medication discrepancies to the MD
"CF RPh will be responsible for inpatient CF Med Rec process
"Standardized CF Med Rec process:
PMLRF initiated ideally within 48 hours of admission, but must
be completed before hospital discharge
accept input from all CF team members
utilize at least 3 sources of BPMH information: ambulatory
medication list, previous hospital admission, eHealth drug
profile viewer, patient, community pharmacy, etc.
identify and calculate number of medication discrepancies
notify MD of medication discrepancies or refer MD to PMLRF
"Implementation: March 8th to April 5th, 2013
26 CF admissions (24 to 6Bond, excluding 2 to MSICU)
4/24 (16.7%) PMLRF initiated by MD, 20/24 (83.3%) by RPh
3/24 (12.5%) pts with no medication discrepancies "Retrospective chart review: January 2012-2013
20 randomly-selected CF admissions to 6Bond
4/20 (20%) PMLRF completed
1/4 (25%) MD-initiated PMLRF; 3/4 (75%) RPh-initiated

"Ambulatory CF Med Rec quality review: March 4-28, 2013
20 randomly-selected CF patients
Medication list documented by clinic RN - 100% compliance
Med Rec performed by RPh - 100% compliance
19/20 (95%) patients - RPh-identified medication
Figure 4: Inpatient CF Med Rec adherence and quality (March 8 - April 5)
Process Measure Outcome Measure
% Med Rec =
# of completed PMLRF /
# of CF admissions
# of medication discrepancies
Figure 3: Process and Outcome Measures