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Medication Reconciliation - A Maine Critical Access Hospital Story
A patient has brought two different prescription inhalers to the hospital, each prescribed by a physician unaware of
what the other had prescribed. She is using both, each day, doubling her prescribed dosage.
A physician office staff member, preparing a discharge for a patient and utilizing electronic medical records, means
to ‘click on’ Carafate, a digestion prescription, and instead clicks on Cardizem, a cardiac medication. The
paperwork is printed off and given to the patient. Fortunately, before the patient filled the prescription she called the
doctors office as she had never seen this prescription before. She was right.
A patient goes to his neighborhood pharmacy, renewing all prescriptions from his family doctor. He then fills a new
prescription from a specialist – but at a different pharmacy. He didn’t tell the new provider of the prescriptions he
was already taking. He is now risking taking drugs that could have harmful interactions.
Think these events can’t happen? “They are happening every day,” notes Bobbi Cribby, BSN, MS, Director of
Clinical Practice, and Denyell Gerchman, RPh, Bridgton Hospital Pharmacist and co-directors of a major medication
safety initiative launched at the hospital in June 2009 and funded through a Maine Health Access Foundation Grant
to the fourteen Maine Critical Access Hospitals. Proof of the Problem
According to Cribby, 25% of all medication-related injuries are due to preventable medication errors. In addition,
errors cost hospitals more than $3.5 billion each year and one-third occur in outpatient settings, reflecting an
additional $1 billion annually. Also, the over-65 age group takes roughly 1/3rd of all prescription medicines and they
could be receiving medicines from as many as eight different physicians at any time. This population is at a
significant risk of hospitalization due to drug safety issues. The hospital identified through their pharmacists
inaccurate medication lists being obtained through triage in the emergency department as well as other points of
patient contact. If it is happening here, it’s happening everywhere! For numerous reasons, a physician office paper or
electronic medication list can be inaccurate. Why is that important? Clinical staff in the hospital setting often
depends on office medication records if the patient cannot communicate with them. The Solution
The Maine Critical Access (CAH) Hospital Patient Safety Collaborative began in 2008 with the support of the
Maine Office of Rural Health, Maine Quality Forum, Maine Health Access Foundation, and the Muskie School of
Public Service. Bridgton Hospital is one of fourteen CAH’s in Maine that was awarded a $50,000 grant to work on a
medication safety project. The multidisciplinary team, including physician leadership, nurses, pharmacists, direct
patient care departments, IT, and physician practice staff chose ‘Medication Reconciliation with Emphasis on
Patient Education and Community Partner Involvement’ as the focus of their grant. Long title, simple focus: Patient
Things we did? Morning multi-disciplinary meetings now include a pharmacist in attendance. Pharmacists visit high
risk patients at their bedside. Physician leadership educates the medical staff regarding project goals. Emergency
department RN’s proactively work with patients and their families to get accurate medication lists during triage.
Community pharmacists, like Rite-Aid and Hannaford Supermarket, have been actively courted to participate and
identify their challenges and how the hospital and practices can support their best practices. To support our
physician offices, we worked with IT to have a computer generated daily list of their discharged patients. This action
provides a safety net, prompting a medication update of the patient’s office record and a forty-eight hour call to their
patient to review their medications. These calls have helped avoid readmissions due to necessary medication
Consumer Visibility – The Blue Folder Project
Discharge from the hospital is one of the highest risk points for our patients. Working with our physicians we
stressed the critical importance of medication reconciliation at discharge. The nursing staff was educated on the
important role they played in the delivery of information to their patients. Nurses reaffirmed the importance of the
patient having an accurate listing of their medications for their healthcare visit contacts – from physician office to
pharmacy. With this accurate information in hand, we now could launch what would become the publicly visible
‘Blue Folder Project’.
The group could have simply provided discharged patients with a paper folder to place their paperwork, an
economical solution certainly. However, to be customer/patient friendly, we wanted something more visible, and
certainly longer-lasting, for our patients. Thus was born ‘The Blue Folder’, a substantial blue vinyl portfolio with the
hospital name on the front and inside a place to keep discharge papers and prescriptions safe and conveniently
located. An addition was a barcode on the reverse to track usage, not patient data but its actual use, at practices,
outpatient clinics and the inpatient unit.
The Blue Folder Project began by concentrating on discharged inpatients at Bridgton Hospital. Starting in 2010, the
project rolled out to primary care physicians including Internal Medicine and all Family Practices. This rollout
included meetings with practice staff to review the program and stress the importance of their delivery of the Blue
Folder to their patients. Patients will value the objective of the folder if their caregivers believe in its importance.
We have found the caregivers in the practice offices have become fully invested in this safety initiative – they make
sure the medication lists are accurate and that they are provided to every patient on discharge. Anecdotal feedback
from a physician was that seeing their patient with their Blue Folder in their hands reminded them of their
responsibility in reviewing current medications with their patients. The simplicity of a blue colored vinyl folder is
driving practice changes!
“At this time, we’re proud to say that there are eight out of 15 Critical Access Hospitals in Maine that have now
adopted the ‘Blue Folder’ for their own medication safety initiatives,” notes Ms. Cribby. “We now have twenty
thousand blue folders being dispersed to patients throughout the State of Maine. Again, the goal is for patients to
take the folder to all key points of medical services.
Our experience is that patients have turned this ‘simple’ blue folder into their healthcare folder. We have sometimes
underestimated how patients truly want to have more control of their healthcare. Healthcare settings can be
paternalistic. We want to care for our patients. We are pleased that a majority of our patients demand to be active
participants with their healthcare. Our folder tracking program for the past six months has verified this, showing
nearly three thousand healthcare encounters.
A recent example was brought to the hospitals attention concerning a patient in the oncology clinic. As we know,
oncology patients are very often involved in multiple consultations with specialty providers. They also have frequent
medication regime changes. An oncology patient arrived at the clinic with their blue folder, proudly ready to provide
their most recent consultation and medication information to their oncologist. “At a time when life can be out of
control for our patients, this blue folder has placed some control back into their hands,” noted Ms. Cribby.
Future Opportunities and Challenges
Every healthcare organization is challenged financially. The project exists right now at Bridgton Hospital, a 25-bed
Critical Access Hospital, part of a three hospital system, Central Maine Healthcare. A significant challenge –
financially as well as human resources - will be to roll it out to the other hospitals and practices.
Funding for the Blue Folder Project is of concern. Although we have negotiated the per piece price dramatically, this
is considered a ‘soft expense’ and not necessarily critical to our patients care. However, our patients think
differently, and the feedback we have received verifies this.
The reality is as follows: As with all quality care initiatives, maintaining the momentum is a challenge; keeping
medication safety forefront in a staff members mind is a challenge; increasing local and statewide pharmacy
involvement at a time when our patients are known to ‘pharmacy hop’, seeking the best prices, is a challenge.
The project has caught the attention of national groups as well. Ms. Cribby and Ms. Gerchman were participants at
the December 2009 Institute for Healthcare Improvement Conference in Orlando, Florida, and Ms. Cribby presented
the project at the 2009 Annual Hawaii Medicare Rural Hospital Conference and the July 2010 National Rural
Health Association Quality and Clinical Conference.
For further information contact Pamela Smith, Director, Bridgton Hospital, Development and Community Relations,
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