Medication Reconciliation By Michelle Schneider, RN

Whenever a patient moves from one "setting, service, practitioner, or level of care within or outside the organization," the complete and current list of that patient's medications—as obtained on admission/entry and updated during that episode of care—will be communicated to the next provider of service to be compared (reconciled) with the medications to be provided in/by the new setting, service, practitioner, or level of care. The list will reflect changes that occurred during the episode of care.

The process of creating the most accurate list possible of all medications a patient is taking This should include: drug name dosage frequency route

Is affected by Medication Reconciliation?

“The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been.” Donald M. Berwick, MD, MPP President and CEO Institute for Healthcare Improvement

Patient ER/Admitting Nurse ER/Admitting Doc Hospital Pharmacist Every Clinician who comes into contact with the patient Retail Pharmacist Physicians – Inpatient and Outpatient

Patient Admitted Med History Obtained Admitting Physician Sees Patient Med History Obtained Orders Written Substitutions/ Omissions As needed Patient Transferred New Orders written Patient Discharged Discharge Prescriptions Provided Patient Presents to Physician Post-DC Orders reviewed There are so many opportunities to make or break the Medication Reconciliation process Patient Presents to the ED Med History Obtained

ER/Admitting Nurses and Doctors Q. Do I have to acquire the list of patient medications in an emergent or urgent admission/entry situation? A. In urgent situations or when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status immediate care takes precedence. At the point when the patient is stabilized and the organization has the opportunity to acquire information about the patient's most current medications, the organization should take steps to acquire this information and compare it to the medications it is providing.

The patient is the common denominator throughout the continuum of care. If we can educate the patient about the importance of medication reconciliation then we have a much better chance at success.

Poor Historian – Incorrect Home Med List Similar drug names Home Med not on formulary – therapeutic substitution/interchange Meds DC’d on Admission – Acute care

1.Scheduled Admissions Make the expectations clear to the patient prior to the hospitalization Send home a letter and a form for the patient to fill out. It is often less stressful to complete the medication list at home. Include primary care physician and retail pharmacist Obtain the home medication list as quickly as possible. Involve significant others Educate patient and SO’s of the importance of an accurate list Get medications from home if needed Include primary care physician and retail pharmacist 2. Emergent Admissions

3.Therapeutic Interchange 4.Home Med DC’d on Admission Document on order – What drug does this replace Document in Pharmacy order – Therapeutic Interchange Document on original Home Medication list Print on DC somewhere – “The following were replaced on admission” Order this drug as a HOLD medication – Indicate on order “HOME MED” Document in Pharmacy – Home Med held on admission Print on DC somewhere – Be sure patient knows whether or not a medication should be continued at home

YES –Are all components the same? YES - Drug, Dose, Sig, Route – Complete NO – Notify physician - Flag for review/Patient Education NO –Has physician confirmed purposeful omission? YES – complete. Flag for review at DC NO – Call physician to confirm – Flag for review at DC

The Joint Commission does not require a specific form – electronic or paper The list must be complete on Admission The list must be accessible to all who need it

Paper still seems to be the most common place to store the home medication list The computer is the best place if we could only make it look like those pretty forms!!! If we can get it in there somewhere – let’s take advantage of it!

ER to Admission ICU to TCU TCU to MedSurg Any Transfer from unit to unit Post-op Discharge

All medications must be discontinued New orders must be “written” –The Good Review Medication list Confirm accuracy and need –The Potential pitfalls Potential for transcription errors Potential for omissions Potential for delayed, duplicate or missed doses Multiple transitions make it difficult to have one form for the visit

Q. What is meant by "completely reconcile?" A. In this context, reconciliation is the process of comparing what the patient/client/resident is taking at the time of admission or entry to a new setting with what the organization is providing to avoid errors of transcription, omission, duplication of therapy, drug-drug and drug- disease interactions, etc. It is up to each organization to determine how this process takes place. Whenever and however the comparison takes place, it should take place early enough to improve the safety of the organization's medication management processes, and hence patient safety.

Q. What is the expectation under 8b, communication of information to the next provider of service? A. When referring or handing over responsibility for the patient/client/resident's care to another setting, service, practitioner, or level of care within or outside the organization, it is expected that each organization has a process to communicate to the next provider or setting all of the patient/client/resident's current list of medications. It is up to each organization to determine the method of communication of this information. For example, the complete list of medications may be written or communicated via electronic system such as an up-to-date electronic MAR that can be accessed by the receiver, etc.

Home Medications – What about the med that was discontinued on admission? Can it be restarted now? Pre-transition Medications – This list will be used to build the new list.

Be sure Home Med list is easily accessible –If on paper Keep in a consistent place Scan and make accessible from a query or from PCI Find a method to make the pre-transition med list easily accessible in its pre- transition state –Find a way to take a snapshot of that list

Gather your tools: –Home medication list –Current medication list –Discharge medication list

“One of the most common errors at discharge is failure to resume medications that the patient should be taking," said JCAHO's Richard Croteau, executive director for strategic initiatives.

New Medication –Is this replacing a Pre-Admission med? YES – Educate patient to discard previous med NO –Prescription given –Education monograph given Meds DC’d on Admission –Should the patient return to preadmission regimen? YES – No new prescription. Include medication on discharge list NO – Educate patient what to do with leftover meds

Therapeutic Interchange –Will the patient continue on previous med? Yes – No new prescription. Include on discharge list and provide education. No – Educate patient what to do with leftover meds Same Drug/Different Dose –Can patient use dose at home for new order? YES – Instruct patient NO – Instruct patient to discard previous prescription and provide new prescription.

Making future visits less stressful Educate patients Make patients part of the solution Give patients a list to keep at all times Instruct patients to bring to all visits – Ask providers to update Keep updated at all times

Joint Commission » Institute for Healthcare Improvement » Massachusetts Coalition for the Prevention of Medical Errors » Institute for Safe Medication Practices » The American Journal of Health-System Pharmacy »

Thank you and enjoy MUSE!! Michelle Schneider, RN Product Manager Iatric Systems, Inc This presentation will be available for download at