Prescriber Education Medication Reconciliation Patient Safety Initiative

Why Med Rec? It is a patient safety initiative Reduction of adverse events at key transitions of care (adm, transfer, disch) One of the WHO top 5 patient safety initiatives² Structured communication process that formalizes what we already do Required for Accreditation HC professionals partner with clients, families and caregivers for accurate and complete transfer of medication information¹ At the monthly management meeting of a large urban hospital, the head of patient safety announces: “We had a critical incident last week. A patient was readmitted two days after discharge with severe hypoglycemia. The treating team discharged the patient on a new insulin regimen without realizing that the patient also had insulin 30/70 at home. The patient continued to take her previous regimen as well as the new one, and was found unresponsive by her husband. She’s in the ICU and probably will have permanent neurological deficits.” After various sighs and exclamations from around the table, the chief medical officer asks, incredulously, “Why didn’t this get picked up?” Before anyone can answer, the executive adds: “We had that other case six months ago in which a patient was discharged without restarting his warfarin, and he ended up having a stroke.” Adapted from: Fernandez O, Shojania K. (2012). Medication Reconciliation in the Hospital. What, why, where, when, who and how? Healthcare Quarterly Vol. 15 Special Issue 2012. ¹Accreditation Canada ROP ²World Health Organization

Admission Gleason et al (2010). MATCH study. Vira et al (2006). 85% med errors originate in medication histories, almost half were omissions Risk Factors (age, #meds). (J Gen Int Med) Vira et al (2006). 60% admitted pts had unintended discrepancies. 18% clinically significant 75% of these were intercepted by MedRec before pts suffered harm (Quality and safety in healthcare).

Discharge Intervention (MedRec) vs. control groups 33.5% medication discrepancies at discharge with MedRec 59.6% in control group (Walker et al, 2009 Arch Int Med) Impact of a Pharmacist-Facilitated Hospital Discharge Program:  A Quasi-Experimental StudyArch Intern Med. 2009;169(21):2003-2010

How does it work? BPMH Reconcile Document Review at transfer MedRec at Discharge Audit

Admission Best Possible Medication History (BPMH) is the cornerstone of the MedRec admission process. Home medication history Reference point for clinical decisions to continue, discontinue or modify home medications during key transitions of care Medication orders on admission (once reconciled and signed by prescriber) Ideally completed within 24h of admission A BPMH may be completed prior to, or alongside, all other admission orders being written (Proactive/Prospective Model) or After initial admission orders have been written (Retroactive/Retrospective Model).

BPMH Sources used to obtain history Date/Time the history completed All prescribed home Medications [including Over-the-counter (OTC) medications if they were PRESCRIBED to pt.] Self-prescribed Medications – (for information purposes only) Additional Comments (information purposes only) Reconciliation section (Prescriber Use Only) Prescriber signs & includes date and time of reconciliation Page #s If prescriber would like to order any of the patient’s self-prescribed medications, they must do so on a Prescribers Order sheet separately

BPMH Goal: Complete, accurate list of patient’s HOME medications Document how the patient is ACTUALLY taking the medication…do not assume If pt taking it differently than prescribed, note how it was prescribed in the Comments section. Use generic drug name whenever possible

BPMH - Sources Ideally, validate the history using at least TWO (2) sources of information. Pt/Family, bubble packaging, med list, Netcare PIN, MAR from another facility, Community Pharmacy printout, etc. 2 sources may not always be available Netcare Medication Profile/PIN is only ONE of many potential sources and is not always accurate! Document the sources used on the BPMH sheet (checkboxes)

See handout copy

Medicated creams/ ointments Interview Tips: “HEAD TO TOE” Eye drops Ear drops Medicated creams/ ointments Inhalers Injections Nasal sprays Medicated patches Prompt questions starting from the head to toe Are you using any: Acetylsalicylic acid Eye drops Ear drops Nasal sprays Inhalers Injections Medicated creams or ointments Medicated Patches Vitamins, herbals or minerals Over-the-counter products (OTCs) and; Have you taken any antibiotics in the last three months?

When do I NOT need to complete a BPMH? Direct admits from another facility If they already have a completed admission BPMH (copy to be faxed to your site). The BPMH will not serve as inpatient orders, only as a history/reference A new BPMH does not need to be completed. Write admission orders per usual process pre- MedRec implementation (using other facility’s BPMH and transfer orders as reference) Exception to the rule!! This is because the BPMH is intended to represent HOME medications. For example, patient admitted at RAH – admission BPMH completed there. Then the patient was directly sent to GNCH from RAH. At GNCH, a new BPMH is not required to be done; the team is to refer to the RAH BPMH. This is what we would call an external transfer, technically. This way, when the patient is discharged from GNH, they can refer back to the original BPMH. The patient needs to know what has changed from their HOME medications.

How to Complete the BPMH Tool The admitting prescriber will be completing the BPMH for all non-elective admissions (i.e. ER admits and direct admits. Exception: Vascular Direct admits during clinical pharmacist hours will be completed by Pharmacist, if available) All elective admissions will have a BPMH previously completed by a Pharmacy Technician in Preadmission Clinic (PAC) See “How to Fill Out a BPMH Tool” and more on CompassionNet www.compassionnet.ca Care and Safety → Medication Management Initiatives →Medication Reconciliation The collection of a patient’s medication history is not new. What is new is the creation of a structured process to ensure the medication history is comprehensive and accurate and that all the discrepancies are addressed.

BPMH Documentation: Even if a medication is an OTC product, it is still written in the top/main section IF it has been PRESCRIBED/recommended by a licensed health care professional. If it was not prescribed to the patient, document in the Self-Prescribed Section (see next slide) Information Sources can include: medication vials, bubble packs/dosettes, Alberta Netcare PIN Profile, medication discharge plan, etc. A list and explanation of the information sources can be found in the HOW TO: Complete Admission BPMH Guide in the Champions Handout.

Self-Prescribed Medications Section Any medication(s) the patient independently decided to take. If you would like any of these to be continued in hospital, additionally write an order for them on the Patient Care Order (pink) sheets.

Reconciling the BPMH This is the section where the prescriber orders to continue, discontinue, or change the HOME medications, and WHY

What do the columns mean? “Continue”: The prescriber would like the medication to continue in hospital exactly as written. This serves as a Prescriber’s Order. “Discontinue”: The medication will be stopped. Please include REASON. “Change”: The medication will still be ordered, but in a different way. (Changed dose, route and/or frequency). Please include REASON. Additionally, write the new order on a Patient Care Order (pink) sheet. This is the RECONCILIATION. Always make a note of any previously written orders if there are any. TIP: instructions are on back of sheet!

What if I discover after the BPMH has been reconciled and processed as orders that a HOME medication was missed on the original list?

Late Entries/Addendums New information may be learned about the patient’s HOME medications after the BPMH is processed. Because this history is referred to at all key transition points, it should be as accurate as possible. Any licensed health care professional may document an addendum. Write “Late Entry” along with the name, dose, frequency and route of the medication Date, time and sign your entry If there is no room, start a new admission BPMH page and renumber all associated pages Whoever discovers the info should document the late entry (RN, Pharmacist, MD, NP).

Late Entries/ Addendums As usual, Prescriber will be notified to address the discrepancy NOT to be processed/scanned to pharmacy again Any orders needed are to be written on the Patient Care Order (Pink) sheets C SCANNED

Where will the BPMH be kept? The BPMH will be kept in the Patient Care Orders Section (pink sheets) of the chart It will be the top page of the section and be placed opposite the pink sheets This is so the BPMH is easily accessible for review when the prescriber writes orders

What are my responsibilities? Admitting prescriber completes: HOME medications “History” (left) section for all non-elective admissions (ER and direct admits) within 24h of admission*. *See exceptions on flow map All elective patients will have a BPMH previously completed in PAC by a Pharmacy Technician BPMHs will be completed typically in ER. BPMHs will be placed in a clear sleeve in the doctors orders section, along with any other documents used to create it (PIN, med lists etc.)

ADMISSION FLOW MAP

When to reconcile? It is at the discretion and clinical judgment of the admitting prescriber whether to complete the Prescriber Reconciliation section at admission (pre-op) or to wait until post-op This will depend on imminence of the surgery, etc. In either case, the BPMH can only be reconciled and used as orders ONCE (pre-op OR post-op, not both).

What are my responsibilities? Write any other medication and non- medication orders, including any changed home medications, on a regular Patient Care Order (pink) sheet. Document and address late entries (if other staff discover an addendum, they will notify you, per usual practice.)

Tip Any other place the medication history needs to be listed; “See BPMH” may be written or stamped.

Transfer

Transfer A change in service and/or level of care within the facility ex. Grey Nuns Surgery to Grey Nuns Internal Medicine  Attending physician rotation (on same service) is not considered a transfer Within-service bed changes are not considered transfers When the doctors on the same service rotate through on a weekly/biweekly basis, this is not a transfer. Important to stress here the “common lingo” of transfer and how the word is misused. a change in service, service provider, and/or level of care within the facility (eg. unit-to-unit transfer including from the intensive care unit to medicine unit and/or from vascular surgery to internal medicine)

Patient physically leaves the facility Transfer vs. Discharge MedRec Transfer Discharge Patient remains within the facility From Unit To Unit Patient physically leaves the facility Out of the Hospital Setting (ex. Home, group home, independent living) OR Out of a facility to another healthcare facility (ex. Grey Nuns Hospital to Youville Home) CIS calls it a “transfer” from GNH to RAH, but in our terms, and health record’s terms, the correct terminology is DISCHARGE

What do I complete on transfer? A sticker will be used. Formally documents in a standardized fashion that you have reviewed the BPMH and current medications prior to patient transfer. Stickers at GNH will be white.

What about IMCU Transfer to Ward? (GNCH Only) Prescriber will check off this box on the Preprinted Orders Page 3 of the PPCO – just before signature.

What are my responsibilities? Review BPMH and current medications prior to patient transfer within-hospital. Place MedRec Transfer sticker on Patient Care Orders (pink) sheet along with any transfer orders you are writing. Sign, date and time the sticker.

Discharge Or Medication Profile Healthcare providers compare the most up-to-date medications the patient/resident was receiving on the unit (Medication Administration Record (MAR)) with those that were being taken at home (Best Possible Medication History (BPMH)) to determine the patient/resident’s discharge orders. This is documented on the Medication Reconciliation Discharge Medication Order and/or Prescription tool

Please Note: ********** The MedRec Discharge Tool will be completed for Vascular Surgery discharges ONLY at this time, and only when the Vascular Pharmacist is on duty and able to assist with completion. **********

Discharge MedRec Tool Date and Time Community Pharmacy Information Prescribers Orders Bubble Packaging Requested Discharge Medication List Discontinued Medications (Prescribed and Self-prescribed) Prescriber Name and Signature Unit Contact Information Prescription/Quantity Page #s Other Important Information Community Pharmacy Information

Why a Discharge MedRec Tool? Complete and accurate list of discharge medications Plus a list of discontinued home medications Once signed by prescriber: Discharge medication orders (if patient going to another facility) and/or Prescription (if a quantity specified) Replaces current discharge prescription process Includes OTCs and prescription medications.

Discharge Tool Lists all medications the patient is to take after being discharged from the site. Beside each medication, it is indicated whether the medication is: Continue – Unchanged PRE-ADMISSION medication Changed – PRE-ADMISSION medication has been changed during hospitalization (dose, route, or frequency). Include rationale in space provided. New – New medication started while in hospital. Include rationale in space provided. In the “Discontinued HOME Medications” section (see stop sign), any HOME medications that were discontinued during hospitalization and are NOT to be given on discharge, are listed. Includes OTCs and prescription medicaitons

Discharge Tool When a prescription is required, quantity +/- refills is indicated in the designated columns If no qty or refills are required, strike a line through the column(s) Triplicate (TPP) medications should still be listed on the discharge tool to ensure the list is complete Additionally, a Triplicate Prescription is required (unless the patient is going directly to another inpatient facility) FYI: Instructions are also on the back of the white copy (top copy) of the form Includes OTCs and prescription medicaitons

Discharge Tool: Two-ply White ply: Chart/Prescription copy. Can be faxed to community pharmacy, etc. Yellow ply: Copy for patient/caregiver for their records White ply: Chart copy. If ordered, can be faxed to appropriate receiving community pharmacy and/or facility, as well as to the patient’s family physician. If patient would prefer to take this copy in person to his or her pharmacy, a copy of it must be made to keep in the chart. Yellow ply: Pre-marked as “not a prescription”. Copy for patient/resident or caregiver for information purposes (to be provided along with patient ply of the Short Stay Discharge Summary Form). Patient/caregiver will always receive this copy of the tool.

Discharge directly to another facility Discharge tool serves as discharge medication orders that can be faxed to the next facility. All other non-medication related discharge orders should be written as per usual on the Patient Care Order (pink) sheets. The admission BPMH should be faxed to the receiving facility along with the Discharge Tool. Check off “Send Admission BPMH” This provides the receiving facility with an understanding of the patient’s home medications as well. If the patient is being sent directly to another healthcare facility, it is important that in addition to sending the Discharge MedRec tool, the admission BPMH is faxed to them as well.

DISCHARGE FLOW MAP

What are my responsibilities? Discharging Vascular Prescriber to liaise with Vascular Pharmacist who will assist with completion of the tool when available on duty. (Usual hours M-F 0800h-1530h) Sign/date/time the MedRec Discharge Tool (Prescriber must complete final review/signature). If Clinical Pharmacist is unavailable, Discharge MedRec will not be mandated.

Tip Any other place the discharge medications need to be listed, “See MedRec” may be written or stamped.

MedRec Resources MedRec Flow Sheet/Responsibilities Poster CompassionNet Internal (How To) and External Resources MedRec Policy VII-B-235 On Deck with MedRec Newsletters MedRec Info Binders Binder will be at unit clerk’s desk MedRec Flow Sheet/Responsibilities Poster Will be posted on your unit MedRec Project Team medication.management@covenanthealth.ca Will show on next slide how to get to the MedRec CompassionNet landing page.

MedRec Page: CompassionNet 1. Go to www.compassionnet.ca Tip: Add to bookmarks, or a shortcut on desktop  2. Click “Care & Safety” 3. Then click on 4. Then click on

When does implementation begin? Monday June 15, 2015 Until then, follow current unit practices already in place.

Local Implementation Begin with “Kick-Off Event” – see posters Week One: Project Team is physically present on site for first week and via pagers Support the MedRec Champions Coaching & guidance for local staff on the use of MedRec tools/processes Week Two: Project Team available remotely via pagers Two weeks in: auditing commences End with “Celebration Event” – see posters Kick off June 15th, Celebration June 25th.

Questions/Feedback? Local Unit MedRec Champions MedRec Team During implementation dates: in-person and via pagers; (pager hours will be posted on the units) Pager #1: (780) 445-5398 Pager #2: (780) 969-9879 Any time at: medication.management@covenanthealth.ca Pager numbers will be posted on your unit at main desk. To reach us instantly for those issues/questions that arise in the moment – page if you don’t see one of us!