use space to insert photo or graphics accessed through Title Master Slide Update date on title master slide use space to insert photo or graphics accessed through Title Master Slide Update date on title master slide Medication Reconciliation Preventing adverse drug events one patient at a time. Linda Cawthorn, RN, MN (can) Kim Spiers, BScPharm Shelly Proft, BScPharm

Objectives Background Information Define Medication Reconciliation Instructions for completing the Med Rec Form Case Study How to take a medication history Roles and responsibilities Case Study

Accreditation Standards Medication Reconciliation is a new Canadian Council on Health Services Accreditation Standard “Reconcile the patient’s medications upon admission, and with the involvement of the patient” “Reconcile medications with the patient at referral or transfer and communicate the patient’s medications to the next provider of service at referral or transfer to another setting, service, service provider, or level of care within or outside the organization” Enhances professional practice standards for the College of Physicians and Surgeons, CARNA, CLPNA, and College of Pharmacists.

Evidence from Literature An adverse events among medical patients study showed an overall incidence of adverse event of 23% for discharged patients from a medical unit with 72% of the events being adverse drug events. [i] Implementation of medication reconciliation along with other interventions decreased the rate of medication errors by 70% and adverse drug events by 15%, over a seven month period.[ii] [i] Forester, A., Clark, H., Menard, A., Dupuis, N., Chernish, R., Chandok, N., Khan, A., van Walraven, C. (2004) Adverse events among medical patients after discharge from hospital. CMAJ, 170 (3). [ii] Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm 2003;60:

Evidence from Literature Implementation in a surgical population reduced potential adverse drug events by 80% within three months of implementation.[i] For those with no missing medications, drug related problems after discharge were reduced from 85% with original prescription process, to 35%.[ii] [i] Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care 2004;13(1):53-59 [ii] Poole DL, Chainakul MP, Graham L. Medication reconciliation: A hospital necessity in promoting a safe hospital discharge. J Healthc Qual (NAHQ) 2006 May/June

Transitions in Care Critical Care Unit Operating Room Transitional Care Unit Inpatient Unit Emergency Room Rural Facility Residential Facility Home Community

Medication Reconciliation-What is it? A formal process of: - Obtaining a complete and accurate list of each patient’s current home medications (name, dosage, frequency, route). Using the information obtained for physicians to write the admission orders. Documenting reasons why home medications are changed or discontinued. Bringing discrepancies to the attention of the prescriber and ensuring changes are made to the orders, when appropriate. Referring back to the information obtained to write transfer and discharge orders.

Key Benefits Improves patient safety and reduces errors. Helps obtain the best possible medication history. Enhances patient centered care by involving the patient in obtaining the BPMH. Enhances communication between all care providers across all settings. Matches in-house dose, frequency and route with at-home dose or facilitates proper documentation if change is required.

Key Benefits (cont’d) Prevents inadvertent omission of home medications. Prevents failure to restart home medications following transfer and discharge. Prevents duplicate therapy at discharge from brand and generic name usage or formulary substitutions made while in hospital.

Improve Ambulatory Medication List Improve Admission Medication List Improve Discharge Medication List Improved Accuracy of Medication List Why should we do this? Accuracy and Patient Safety!

Who? Any patient who receives a treatment, procedure or medication in a health care setting Includes ER visits, admitted patients, day procedures, out-patient procedures, radiology procedures (with medications) Exception: Patients who have a Medication Administration Record (MAR) from another facility and who are not going to be admitted. This list must be labeled, reviewed with the patient, signed by the nurse and kept on the chart. The BPMH must be complete on the Medication Reconciliation and Physician Order form prior to the physician writing admission orders.

Patient Label Date and Time BPMH done

List all medications and regular OTC’s how the patient is taking them at home, including name, dose, frequency, route. [MD, NP, RN, LPN, RPN, Pharmacist] Form is to be completed on admission even if patient has no home meds by checking the box and signing the form Draw a line, sign and date just below your last entry. Do not re-write meds on ER record or admitting history

Check ALL sources of information used to obtain BPMH. Keep copies of lists and bubble pack labels etc. in the chart for future reference by other providers. The source of the info gives credibility to the list and assists physician and/or pharmacist in further review of medications. Prevents duplication of effort by the next provider. Use comments section to Document any comments, concerns or follow-up required.

Physicians: Initial ‘continue’ box if home medication dose, route and frequency are to continue as in BPMH. If a home medication is discontinued, initial ‘discontinue’ box and write the reason for not ordering this drug in the ‘Reason’ column. (Remember that the form is being used to communicate to other care providers the changes in therapy).

Physicians: For any change in home medication dose, route or frequency, initial ‘change’ column and complete the reason for the change in the ‘Reason’ column. Write the revised home medication order on the regular physician order form. Sign and date (Draw a line from last med ordered to the physician signature box to prevent further meds from being added without physician approval).

Processing the Orders Check or initial in the ‘Orders Processed’ column. Indicate when orders copied and sent to Pharmacy. Sign and date ‘processed’ line.

Indicate the number of pages used Late Entries; If room, add new information under previous list; if no room begin a new form and draw a line through the orders. Sign and date. Make a comment in the physicians orders to have the new information addressed.

Self prescribed medications These are medications that the patient is taking to treat an illness (cold meds) or as part of health promotion (vitamins or supplements) that are not part of the hospital formulary and will not impact the current hospital stay or management of an existing chronic disease. They will not be continued in hospital unless specifically requested by the patient or physician.

Betty Smith NKDA Admit to Dr. Black - pneumonia Sept 27/ CBC diff, Cr, lytes DAT and AAT O2 sats >91% Daily INR and daily coumadin orders Increase Lasix to 40 mg po daily Levaquin 500 mg po daily Prednisone 50 mg po daily x3 days See Med Rec Form for orders Dr. Black Tylenol 650 mg po bid prn TO Dr. Black/Pharmacist Jan Sept 28/07 Changes to home meds written as new medication orders New medication orders Instruction to see Medication Reconciliation and Physician’s Orders form for home medication orders Discrepancies from ‘Late Entry’’ discussed with physician and new orders written.

Break Out Session Betty Smith Case Study 15 minutes

Break time! 5 minutes

Who has the best med list? Patient’s Actual Medication Use Patient Interview (What the patient tells you) Medication Lists? ≠ Patient’s Medication Regimen Prescribed Medical Chart Medication Wallet cards Community Pharmacist Family MD Labels on Rx vials What is the “truth”?

Practical Tips for Obtaining the Best Possible Medication History (BPMH) 1. Interview the patient (and/or family member) regarding current medications as taken at home. Use medical conditions as a trigger to match medications. Ask about allergies and document reactions on the Regional Allergy Form. 2. Obtain home medication list or medication vials from patient. 3. Don’t assume patient is taking according to label directions. Ask if they or physician have changed the dose or stopped any medication recently.

Practical Tips for Obtaining the Best Possible Medication History (BPMH) 4. Ask if they take non-prescription medications on a regular basis E.g. ASA, vitamins, herbals 5. Ask if using any eye drops, creams, sprays, patches or injections. E.g. Vitamin B12, Eligard®, Fragmin® 6. Ask if physician has given them any samples. 7. Inquire about multiple pharmacies. Teach about using a single pharmacy. 8. Verify accuracy of BPMH by validating with at least two sources of information. (First source is always the patient/family)

Information Sources Patient/family/care giver – best source if patient competent Prescription vials / Compliance packaging Medication List Community Pharmacy – obtain a patient medication profile Family Physician and/or specialist MAR from previous institution, admission netCARE PIN profile Medication Discharge Plan

PIN Profile Date Rx last filled Number of units filled Supply filled for ___# of days Prescribing Physician and Physician phone number Community PharmacyPharmacy Phone Number If days supply is 7, 14 or 28 days, it is most likely that meds are dispensed in compliance packaging.

PIN Limitations DOES NOT include uninsured medications (i.e. paid by cash, administered in an infusion clinic) OTC, herbals, vitamins if medications not provided in a blister pack. DOES provide a starting point to ask the client what medication is taken and how often. As of September 2007 all provincial pharmacies will be on line improving the completeness of the information and will include people under 65 years of age.

Roles and Responsibilities Admitting Clerk: Register Patient Attach PIN profile for all patients. They are requested to print the history, not the PIN profile.

Roles and Responsibilities in Emergency ER Bedside Nurse: Complete nursing admission assessment including Best Possible Medication History (BPMH) prior to physician writing admission orders. Access required information sources. Review lists with patient. Flag form if unable to gather complete info at time of assessment. Ask the next shift to complete.

Roles and Responsibilities ER Charge Nurse: Ensure the Best Possible Medication History is complete prior to physician writing admission medication orders. Return to appropriate nurse to complete Process orders from both the Medication Reconciliation form and Physician Order Form. Check the ‘orders processed’ column. Sign and date on “Processed” line.

Roles and Responsibilities in Emergency ER Unit Clerk: Process orders Send form to pharmacy along with the Physician Order form and Regional allergy form. Sign and date “Orders to Pharmacy” and “Orders processed” if you did them on med rec form.

Roles and Responsibilities in Medicine/Surgery Acute Care Charge RN: Review orders from ER. Ensure BPMH is completed (direct admits & transfers). Reconcile orders with the BPMH. Bring discrepancies to the attention of the physician. In future, use of Med Rec form and current medication profile to determine discharge Rx to be documented on the Medication Discharge Plan. Bedside RN/LPN: Complete BPMH on patients transferred from another acute care setting or direct admits. Do not use the nursing database medication history. Use the Med Rec form.

Roles and Responsibilities Physician: Verify home medication history with the patient. Make a decision about each medication on the list indicating that decision by initialing in the appropriate column (continue, discontinue, change). Document the reason for medications which are discontinued or changed in the reason column. Sign and date the form (making it acceptable as medication orders).

Roles and Responsibilities Pharmacists: Secondary check of order accuracy and completeness. Review appropriateness of therapy. Available for consult for patients with complex medication regimes and for patient teaching. On transfer admissions, available for consult when medications have been changed and insufficient information comes with the patient. On discharge, available to assist with complex medication regimes to improve communication to community pharmacists.

Break Out Session David Becker Case Study 15 minutes

Future Directions Discharge Reconciliation is a formal process of: Comparing the BPMH from admission to the current medication profile and making a conscious decision about every medication on those two lists to determine what medications and doses the patient should be sent home on. Provides a check to determine if all appropriate prescriptions are provided and to ensure that there is no duplication of therapy. Physicians and/or nursing can use these two lists to reconcile medications. Bring discrepancies to the attention of the prescriber.

Future Directions Implementation occurring at all Suburban Rural Communities facilities. Regional expectation that implementation will be complete by accreditation survey, October Implementation at remaining Capital Health sites will begin following accreditation with completion targeted before accreditation 2011.

In Conclusion Strive for Patient Centered Care. Systems Make it Possible but YOU make the difference to the safety of every individual.

References Fernandes, Olavo. (2006). Obtaining a Best Possible Medication History: Sharing Practical Tips, Strategies and Solutions. retrieved from on September 20, Billman, Glen (2005). Medication Reconciliation power point presentation retrieved from on September 20, Northern Health Education session. Retrieved from on September 20,