Problem Addressed

• Medication errors are a common problem: Medication errors are common, especially among older adults, due to their multiple prescription drugs, concurrent conditions, and health care providers.² Of the 89 percent of seniors who reported taking prescription drugs in 2003, nearly one-half took five or more; more than one-half had more than one doctor who prescribed medicines; and about one-third used more than one pharmacy. Among seniors with at least three chronic health conditions, nearly 75 percent took five or more medications regularly and more than one-half did not take all their drugs as prescribed.¹
• Few medication safeguards are available to patients: In primary care practice and outpatient settings, multiple systems (clinics, home, retail pharmacy, insurance plans) and multiple players (doctors, pharmacists, patients, insurance companies) affect medication safety. The burden of safe medication management rests primarily on patients, who traditionally have not been given the tools or resources to effectively manage the multitude of medications prescribed to them.³
• Verification of patient medication list is difficult: One strategy to prevent medication errors is medication reconciliation, which requires listing or verifying a patient's medications and comparing them with the patient's medical record. The verification step involves collecting a medication history and creating an accurate list of medications. Unfortunately, patients may not be able to maintain or provide an accurate history of medication use, and providers may not obtain a complete medication history with every patient. This two-way breakdown in communication leads to errors and adverse events that can have serious consequences.³
• Patient-centered safeguards are needed but often lacking: Patient-centered programs directed at both health care consumers and providers are needed to promote medication safety, but there are few programs that involve both the patient and provider in a collaborative approach.

Description of the Innovative Activity

• Processes to support patients: Based on input from the Patient Safety Advisory Council, the following processes were promoted throughout the community to encourage patients to become more engaged in self-management of their medications:
  • Personal medication lists and a medication bag were designed by the council members.
  • Thousands of the lists and bags were purchased and distributed by council members throughout the community.
  • A public education campaign was launched to address medication safety by encouraging patients to list their medications and/or bring them in a bag to their doctors' visit.
  • Press releases, paid advertisements, and educational programs at residential, social, and public settings as well as other promotional efforts were conducted.
  • Providers (physicians, nurses, retail pharmacists) distributed the medication bags to patients who took five or more medications.
  • Posters and signs were posted in the provider's office encouraging patients to bring their medication list or bags to their next appointment.
• Processes to support provider workflows: Providers, administrators, frontline staff involved in medication reconciliation, information technology staff, transcriptionists, and clerks met to map the medication reconciliation process within each of the five Aurora clinics, including current barriers and opportunities for improvement. Providers also designed a clinic process flow chart to gather preliminary data on the effectiveness and accuracy of the medication lists. Education and training were provided about medication safety, patient-centered care, and how to encourage patient self-management of medications.

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Results

• More accurate medication lists for older patients: The accuracy of medication lists among patients 55 years and older improved by 17 percentage points, from 55 percent before the campaign to 72 percent afterward. The use of any personal medication list by patients seen in the five area Aurora clinics increased significantly, from 51 percent at baseline to 61 percent after the campaign.
• High levels of patient engagement and support: A survey of patients aged 55 years and older seen in the five Aurora clinics found that 76 percent had documented their medications on the list they had received, whereas 73 percent brought the list to their physician appointment. Sixty-nine percent believed the personal medication list made it easier to talk with their provider about their medications. Only 23 percent used the medication bag to transport medicines to their clinic visits, as most patients preferred to bring the list rather than the bag.
• High levels of provider engagement and support: Surveys found that 85 percent of physicians, nurses, and pharmacists agreed or strongly agreed that having patients bring in the medication list form enhanced the accuracy of the medication list on file, while 96 percent believed it helped improve communication. Enthusiasm for the medication bag was somewhat lower, with 54 percent believing it improved the accuracy of the medication list and 88 percent believing it improved communication.
• Broad reach throughout the county: As a result of this program, 8,000 bags and 16,000 medication list forms were distributed during approximately 100 community presentations about the program. A telephone survey of 60 county residents who were not Aurora patients found that 13.3 percent had received a Partners in Safety medication list form, whereas 5 percent had received medication bags. Applying this response rate to the approximately 10,000 Walworth County residents aged 55 years or older, up to 2,600 non-Aurora patients may have been affected by this project.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Creation of Patient Safety Advisory Council: Aurora's project team created an advisory council of patients, providers, and a pharmacist from the region as a vehicle through which providers could partner with patients and the community. Patients who regularly took medications were recruited to participate. All council members attended an orientation session and received background materials on the proposed initiative. The Walworth County Council is not in effect today; however, individual members are still active with the larger Aurora Patient Safety Program.
• Identification of target processes and population: The council reviewed specific process steps in the medication reconciliation process and then assessed how to improve those processes. Through evidence-based research, focus groups, and interviews with providers and patients, the council identified the most important issues related to patient medication adherence and compliance; education of patients, providers, and the community at-large; packaging; and role of technology in the community. Based on this research, the council selected the target populations for the program (patients, caregivers, providers, and pharmacists) and the target processes to be improved, including communication between older patients and providers, supporting patients in self-managing their medications, and redesigning clinic workflows to enhance medication reconciliation.
• Tapping into expert outside resources: The project team reviewed background information from three organizations with expertise in this area, including Consumers Advancing Patient Safety (http://www.patientsafety.org); Midwest Airlines (www.midwestairlines.com), known for outstanding customer service and expertise in selecting prototypes and marketing tools; and Risk Management and Patient Safety Institute (www.geriamori.com). Representatives from these organizations were invited to teach the council about effective communication strategies.
• Community and provider feedback: Aurora presented prototypes for the tools (e.g., medication list forms and bags) to both patients and providers to get feedback. In addition, a patient–provider team worked with the clinics to help improve their medication reconciliation processes. Because attempts to change practice patterns and clinic flows often meet with resistance from providers, Aurora began with simple modifications that could be implemented one at a time.
• Distribution and dissemination: A distribution and dissemination plan was developed and spearheaded by the project coordinator, providing consistency of educational message and a single point of contact.
• Development of measurement and evaluation system: The council developed a plan to measure the impact of the program, including the effectiveness of the tools in improving the medication process and satisfaction and engagement of patients, providers, and community members. The evaluation proved critical in identifying those aspects of the program that should be continued and replicated throughout Aurora and the broader community it serves.

Resources Used and Skills Needed

• Staffing: The program is led by a part-time project coordinator—a nurse who works in the clinics and knows the physicians, staff, and workflow processes. In addition, this nurse works extensively with seniors in Walworth County and is well connected in the community. It is important for the coordinator to know the target group—both providers and patients—as well as the community. Other staffing needs include a strong physician leader to engage and obtain support from other physicians. The leadership of the site needs to endorse the project and to encourage staff to participate in the effort, as well as adopt new processes that are identified. For the evaluation component, staff members are needed who have skills and training in assessment, measurement, and analysis.
• Timeline: A strict timeline should be defined at the start of the project and monitored for compliance. This keeps the project moving forward and avoids distractions that can sideline the effort.
• Costs: Over 2 years, more than $500,000 was budgeted for the initiative's staff, program promotion, mailings, provider training, and products. The following is a sample budget for some of the individual components of the Walworth County initiative:
  • Medication lists: $0.09 each, 10,000 required
  • Medication bag: $3 each, 8,000 required
  • Newspaper ads: $1,400 (1 month of advertisements in eight community newspapers)
  • Patient impact surveys: $5,000 for printing and mailing 8,000 surveys
  • Community impact survey phone calls: $2,250 for 60 phone calls
  • Expert speakers at community events: $500 to $2,000 honorarium

Funding Sources

Tools and Other Resources

• The Aurora Health Care "Partners in Safety" Toolkit is available free of charge at: http://patientsafety.org/file_depot/0-10000000/20000-30000/24986/folder/65244/medtoolkit.pdf.
• What you can do to avoid medication errors. Fact sheet. Institute of Medicine of the National Academies, July 2006. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsfactsheet.ashx.
• Check your meds. Tips for taking medicines safely. Agency for Healthcare Research and Quality, Dec. 2006. Available at: http://www.ahrq.gov/consumer/checkmeds.htm.
• Massachusetts Coalition for the Prevention of Medication Errors. Available at: http://www.macoalition.org/.
• The Med Form. Arizona Hospital and Healthcare Association's (AzHHA's) Safe & Sound Patient Safety Initiative. Available at: http://www.azhha.org/patient_safety/documents/MedFormEnglish.pdf.
• My Pill Box. Available at: http://www.mypillbox.org/mypillbox.php
• The program's 10 steps for creating an advisory council are published in the (free) April 2008 Agency for Healthcare Research and Quality "Guide for Developing a Community-Based Patient Safety Council," AHRQ Publication No. 08-0048.

Getting Started with This Innovation

• Recruit patients, providers, pharmacists, and community stakeholders to serve on a patient safety council, and make sure the council is reflective of age, gender, income, and ethnic groups in the community. Equal representation of both patients and providers on the council should provide a balanced perspective. Changes in council composition can be made as needed once goals are further defined.
• Use focus groups, evidence-based data, and patient and provider interviews to identify key issues.
• Involve the community in the campaign, including through grassroots community organizing, outreach, and education, all of which are vital to the execution of the campaign.
• Disseminate the message through multiple sources, including providers, community leaders, and other respected leaders and organizations and through a variety of media channels that the intended audience regularly uses. Including health care providers such as retail pharmacists, parish nurses, and social service groups facilitates the dissemination of a consistent message that will be heard by a wide audience.
• Involve providers in the process of changing workflows; identify which providers and clinic staff are required to implement the workflow redesigns, and involve them in the change process.
• Create processes and tools to evaluate the impact of the intervention on all affected participants, including patients, providers, clinic staff, pharmacists, and other broader community.
• A strict timeline should be defined at the start of the project and monitored for compliance. This keeps the project moving forward and avoids distractions that can lead the effort off track.

Sustaining This Innovation

• Continually monitor the effectiveness of the program to determine whether additional community education and/or provider process interventions are required.
• Encourage providers to give positive reinforcement to patients who bring in their medication lists or bags; otherwise, they may become frustrated, believing their efforts are not necessary nor valued. One patient representative on the council expressed frustration after he brought all his medications to three clinic visits and the staff never asked to check them.
• With the current focus on Patient Experience, the role of Patient Advisory Councils is being expanded at Aurora Health Care. Currently, three Patient Advisory Councils have been established to identify opportunities for improvement and selecting specific process and/or operational improvements that will better meet the patient and/or family needs around service quality. For example, a Patient Advisory Council at one hospital is implementing new processes around the Discharge Process, which is intended to improve the clinical quality as well as the service quality of the discharge process.

Additional Considerations and Lessons

• Community-based, nontraditional partners can play a critical role in creating a collaborative relationship between patients and providers. This program expands the concept of patient partnering to a broader scale, in both the structures and the processes used. For example, the patient safety council exemplifies the type of partnership between patients and providers that defines patient-centered care but on a community-wide scale.
• Applying public health concepts, interventional methods, and social marketing may be more effective than the traditional medical model for addressing the challenge of medication safety. By creating the educational message and tools for medication self-management in a culturally acceptable format, then disseminating them through community-based organizations, the community itself became empowered to address the public health burden of medication safety. This community engagement, led by formal and informal leaders, was evidenced by the measure of penetration of the project beyond just Aurora patients.
• Although electronic medical records have great potential to reduce the risk of medication errors, process issues still need to be addressed in clinics that have electronic medical records.

Use By Other Organizations

• Aurora is now replicating the collaborative project in other counties where it has clinics. Aurora is also eliciting feedback from its hospital-based patient advisory councils to help redesign medication lists and practices to improve medication safety. In addition, Aurora staff members are working with several regional and statewide organizations to promote accurate medication list initiatives across Wisconsin. In Milwaukee, a group of pharmacists is also working to improve the accuracy of medication lists and medication safety. Pharmacists see patients more often than physicians and are keenly aware of the threat of medication errors.
• Over the past 5 years, Aurora Health Care has shared the lessons learned from this community collaborative through out the country—at national conferences on patient safety and patient experience, to hospitals and health systems, at medical education forums. The Guide has been disseminated to hundreds of health care providers and systems through out the country, as others develop patient advisory councils as a forum for working collaboratively with patients and their community.