Care Transitions and Medication Error Round Up

12 Aug Care Transitions and Medication Error Round Up

This is the final day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding shovel ready interventions and provide a research-based comparison of each intervention discussed this week in a handy chart for you to use.

For another look at how Hope Street Group looks to improve the quality and cost of transitions between acute and other types of care, click here: http://www.hopestreetgroup.org/docs/DOC-2479 .

Shovel Ready Interventions

Three packaged interventions stood out as well evidenced partial solutions that can reduce medication errors during transition of care from the hospital to nursing home or long-term care during the literature review.

MATCH- Medication Reconciliation Tool Kit

Using an AHRQ grant, Northwestern Memorial Hospital created a medication reconciliation toolkit that can be used within either a paper-based or electronic medical system (Northwest Memorial Hospital, 2011). The researchers use a multidisciplinary team based approach to address the entire process as seen in Table 2.

MATCH Tool Kit Components

• Creating a culture of safety
• Assembling a Design Team
• Problem definition by outlining successful practices and identifying current deficiencies within specific organization or practice setting for change
• Development or redesign of existing medication reconciliation process
• Testing and implementation of your new or enhanced medication reconciliation process
• Assessment and evaluation
• Informing and involving patients, families and caregivers in the medication reconciliation process

(Northwest Memorial Hospital, 2011)

This is a tool that is feasible and appropriate to be used in conjunction with a larger strategy to reduce medication errors when a patient is going from a hospital to a nursing home.

Nursing Home Survey Kit (Agency for Healthcare Research and Quality, 2011)

AHRQ sponsored the development of the Nursing Home Survey on Patient Safety Culture. The Tool Kit contains the survey form, survey items and dimensions, user’s guide and feedback report template. An interesting complement to the survey is the comparative database that is a central repository for survey data from nursing homes that have administered the instrument. Preliminary data from 2008 is available from 40 nursing homes and with over 3,500 respondents.

This kit is included because 1) it is an easy way to contribute to the science of patient safety (creating benchmark data) and 2) the participants can use this to trigger organizational learning and change.

TeamSTEPPS (Agency for Healthcare Research and Quality)

TeamSTEPPS is a three-phased, process based, teamwork system designed for health care professionals aimed at creating and sustaining a culture of safety in order to drive quality and safety. While not specifically hospital based, it appears to be focused on large systems as a target for implementation. The Department of Defense and AHRQ partnered for the creation and national implementation of TeamSTEPPS. This is another evidenced based intervention for building teamwork and increasing the culture of safety in an organization.

 Summary

The many factors that lead to medication errors during transition between a hospital and nursing home or long-term care are not easily addressed. Effective interventions are needed at an individual, team and organizational level at within both points of the continuum but also when interfacing with each other.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity:http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Agency for Healthcare Research and Quality. (n.d.). TeamSTEPPS:National Implementation. Retrieved 2011 10-August from Agency for Healthcare Research and Quality:http://teamstepps.ahrq.gov/abouot-2cl_3.htm

Northwest Memorial Hospital. (2011). MATCH Medicatin Reconciliation Toolkit. Retrieved 2011 14-March from Northwest Memorial Hospital: http://www.nmh.org/nm/making+the++case