Nursing Education Medication Reconciliation Patient Safety Initiative Last updated: May 2015

Outline MedRec Basics MedRec Champions Important Dates Admission, Transfer, Discharge Overview and responsibilities Measurement Resources

What is Medication Reconciliation? Patient Safety Initiative Goal: Develop a structured process to ensure that comprehensive and accurate medication information is collected and follows the patient’s journey during key transitions of care (admission, transfer and discharge). Accreditation Canada ROP Requirement The collection of a patient’s medication history is not new. Minimize adverse drug events and medication errors at key transitions of care Enhance transparency of information between healthcare providers and the patients across key transitions of care Patient Safety Initiative to minimize drug errors and adverse drug events Structured & formal process to: identify the most complete and accurate list of medications ensure careful evaluation of medications being added, changed or discontinued at key transitions of care (admission, transfer and discharge) communicate, document and reconcile medication lists at key transitions of care Accreditation Canada Required Organizational Practice (ROP) Requirement 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.

Key Transitions of Care Different processes are in place as patients/residents move through different care settings. The Transition points are: Admission, Transfer and Discharge. We have developed a one page process handout to show all the different duties and responsibilities of each discipline. MedRec structured process for implementation:

Admission MedRec

Admission Best Possible Medication History (BPMH) is the cornerstone of the MedRec admission process. BPMH is: a medication history a reference point for decisions to continue, discontinue or modify the medication regimen during key transitions of care acts as the one “source of truth” serves as medication orders on admission (once reconciled and signed by prescriber)

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

Divisions of Authority to Complete LEFT SIDE: Medication History (may be completed by a licensed Health Care Professional; this includes, but is not limited to, prescribers) RIGHT SIDE: Prescriber Use Only Section of BPMH Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act [Alberta] or the Health Professions Act [Alberta], and who practices within scope and role.

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). In either case, a BPMH should ideally be completed within 24h of admission. Proactive: The admission BPMH is created prior to medications being ordered. Retroactive: The admission BPMH is completed after the admission orders have being written. 25 8.6

Prescriber Reconciliation The Prescriber Reconciliation Section can be completed either: Pre-op or Post-op This will be decided by the Admitting Prescriber on a patient by patient basis Proactive: The admission BPMH is created prior to medications being ordered. Retroactive: The admission BPMH is completed after the admission orders have being written. Ensure you are checking the chart for BPMH orders Pre-op and Post-op, but note that the BPMH can only be used as an order and scanned to pharmacy once

Direct admit from another facility Patients who already have a completed admission BPMH from another site (copy faxed to your site). In this case: The BPMH will not serve as inpatient orders, but as a history/reference only. A new BPMH is not to be completed. 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.

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 their orders

BPMH Tool: Late Entries New information may be learned about the patient’s HOME medications after the initial BPMH is processed. Any licensed health care professional may document the new information so the home medication history is as accurate as possible If there is no room, start a new admission BPMH page and renumber all associated pages If new information is learned about the patient/resident’s preadmission medications after the initial BPMH is completed and signed, it is still important to capture this new information. Write a late entry on the BPMH tool itself. If there is room on the original BPMH, write “Late Entry” along with the name, dose, frequency and route of the medication, date, time and your signature. If there is no room, start a new Medication Reconciliation tool and renumber all associated pages. Additionally, write this information in the progress notes and notify the prescriber to address the discrepancy.

Late Entries/ Addendums Write “Late Entry” and the name, dose, route and frequency of the medication Date, time and sign your entry Notify the prescriber to address the discrepancy Do NOT process/scan to pharmacy again Any orders needed are to be written on the Patient Care Order (Pink) sheets C SCANNED

What are my responsibilities? PRESCRIBERS will be completing the BPMHs (not nursing) Nursing will however be responsible for the documentation and notification of prescriber re: any late entries Alternatively, you can flag to your Charge Also, flag to your charge nurse if your patient has been admitted more than 24h and they do not have a completed BPMH in their chart. Check to see if BPMH is used as orders Pre-op and Post-op BPMH can only be processed as orders once (either Pre-op or Post-op) If you discover a missed/incorrect home medication after the BPMH is already completed and processed. Or if there were any changes to what was written above. Or consult the team’s pharmacist if you are unsure.

Transfer MedRec

Transfer A change in service, and/or level of care within the facility ex. Grey Nuns Surgery to Grey Nuns Internal Medicine  If the attending physician changes/rotates but the patient remains cared for by the same service, this 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)

Is there a tool for transfer? There is no paper “tool”, but a neon green sticker will be used. It is signed/dated/timed by the Sending and Receiving prescriber and included with any transfer orders written. A sticker will be placed on the Patient Care Order by the UNIT CLERK at the time of transfer This sticker/stamp is a way for prescribers to formally document in a standardized fashion that they have reviewed the BPMH and current medications prior to patient transfer.

Receiving a Patient within the Facility If the Surgery Program is receiving a patient from another service, the Receiving Prescriber will sign the MedRec Transfer sticker acknowledging the BPMH medications and current medications have been reviewed Good to know about it in case any prescribers on your team ask. You can still provide information and support, as well as remind them!

Sending a Patient within the Facility If the Surgery Program is sending a patient to another service, the Sending Prescriber will sign the MedRec Transfer sticker acknowledging the BPMH medications and current medications have been reviewed Exception: “Vascular IMCU Transfer Orders” PPCO will have a check box on the last page to indicate when this task is completed. The PPCO reads: The above orders were created upon review of the patient’s current medications and Best Possible Medication History (BPMH) Good to know about it in case any prescribers on your team ask. You can still provide information and support, as well as remind them!

IMCU to Ward – GNCH Only Prescriber will check off this box (No sticker will be required) Page 3 of the PPCO – just before signature.

What are my responsibilities? Nursing has no official responsibility at transfer Be aware of the process help to remind prescribers this needs to be done on transfer of service within-hospital Good to know about it in case any prescribers on your team ask. You can still provide information and support, as well as remind them!

GNCH - Vascular Service Patients Only Discharge MedRec GNCH - Vascular Service Patients Only Note: For all Non-Vascular Surgery Patients (i.e General Surgery, Ortho Surgery, Gyne Surgery etc), Discharge MedRec will not be completed. Please continue with your current Discharge Process.

Discharge Refers to the end of service provision by the care facility i.e. the patient physically exits the current facility and subsequently goes home or to a different care facility Discharge to another facility: This refers to moving between facilities, where the patient physically exits the current facility and goes to another health facility setting (ex: to another hospital, long-term care facility).   Discharge to home/community : This refers to when the patient physically exits the current facility and subsequently goes to home/community setting (ex: to home, independent living, group home). Tip: “Elvis has left the building” and is not returning (Case number is closed)

Transfer vs. Discharge Patient remains within the facility From Service To Service Patient physically leaves the facility Out of the Hospital Setting (ex. Home, group home, independent living) 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

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 and/or Prescription (if a quantity specified) This will replace current discharge prescription process Includes OTCs and prescription medications.

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

Discharge Tool: Two-ply White ply: Chart copy. If patient would prefer to take this copy in person to his or her pharmacy, a copy of it must be made for the chart. Clearly mark the photocopy as, “CHART COPY.” Yellow ply: Copy for patient/resident or caregiver for information purposes Provide along with yellow copy of the Short Stay Discharge Summary Form. Patient/caregiver will always receive this copy. 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.

If Discharge Tool is faxed to a Community Pharmacy In this case, the patient will ONLY receive the Yellow copy Please ensure that if the tool is faxed for prescription purposes, the patient does NOT also receive the original (white) copy of the prescription – this would be the equivalent to the patient receiving TWO prescriptions!

What if the patient does not have a BPMH? Effective the start date of implementation, a discharge MedRec tool is to be completed for ALL VASCULAR SERVICE patients being discharged Even if there is no official BPMH in chart from admission. Eventually all patients will have a BPMH so this will get easier. There will be a transition period where patients were admitted prior to implementation and may not have an official BPMH for comparison on discharge. Please complete the discharge tool based on comparison with the chart medication history or pharmacist’s BPMH in progress notes.

What if the patient was admitted before MedRec implementation started? These patients will not have a formal BPMH in chart Effective the start date of implementation: Discharge MedRec tool is to be completed for ALL VASCULAR SERVICE patients being discharged. Eventually all patients will have a BPMH, so this will get easier. Effective the start date of implementation: Discharge MedRec tool is to be completed for ALL patients being discharged. There will be a transition period where patients were admitted prior to implementation and may not have an official BPMH for comparison on discharge. The discharge tool will be completed based on comparison with the chart medication history or pharmacist’s BPMH in Progress Notes.

Discharge directly to another facility BPMH should be faxed to the receiving facility in addition to the discharge MedRec tool. This provides the receiving facility with an understanding of the patient’s home medications, as a point of reference. 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.

What are my responsibilities? Help ensure the patient/caregiver always leaves the facility with yellow copy of the discharge MedRec tool If the patient is additionally going to be given the white prescription copy (top copy) to take to their pharmacy, a photocopy will need to be made for the chart. Clearly mark the photocopy as “CHART COPY” Liaise with the team pharmacist (if available) to ensure the patient has been provided explanation/education re: any medication changes. Remember: If the prescription (white page) was already faxed, the patient leaves with the yellow copy ONLY.

Measurement and Evaluation

Measurement and Evaluation: Auditing: Auditing of admission and discharge MedRec will occur on a monthly basis by your unit’s designated auditor. Measure Question Success Measure Was MedRec completed? Quality Measure Was it done well? Outcome Measure Were there any discrepancies? It is broken down into 3 measures. Check out your unit’s board for baseline data! Will be updated as audit results come in! Starts out monthly but if results are good, the frequency goes down. The 5 quality elements are; Two or more sources for the BPMH Actual medication use verified by the patient/ family Complete medication information (right name, dose, strength, route) Every medication is accounted for in the admission orders and Rationale included for changed and discontinued medication orders

MedRec Resources MedRec Flow Sheet/Responsibilities Poster CompassionNet Internal and External Resources MedRec Policy On Deck with MedRec Newsletters MedRec Info Binders Binders will be at Unit Clerk’s desk MedRec Flow Sheet/Responsibilities Poster In report room 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 2. Click “Care & Safety” 3. Then click on Tip: Add to bookmarks, or a shortcut on desktop  4. Then click on

If I have questions, who do I ask? MedRec Champions MedRec Team During implementation dates: in-person and via pagers; Pager #1: (780) 445-5398 Pager #2: (780) 969-9879 After implementation dates: via email To reach us instantly for those issues/questions that arise in the moment – page if you don’t see one of us!

Contact Us Do you have proposed changes to the MedRec work? Complete a “Change Request Form” (available on CompassionNet) Submit to: Medication.Management@covenanthealth.ca Questions? Feedback? Email medication.management@covenanthealth.ca All change requests will be brought forward to the MedRec Project Team and Project Executive Sponsor (if required) for discussion and decision. Submit to Meilai Ha, MedRec Project Coordinator. Questions, feedback? Email: Please email the MedRec Team at the listed email address.