2. HEADS UP TO A SAFER HEALTH CARE AT THE GLACE BAY HOSPITAL Medication Reconciliation

3. Prepared and Presented by : The Medication Reconciliation Champions 1. Billy MacPherson 3 rd South/West.1. Billy MacPherson 3 rd South/West. 2. Carol Tobin I.C.U. Dept.2. Carol Tobin I.C.U. Dept. 3. Sharon Moore 3 rd West Medical3. Sharon Moore 3 rd West Medical 4. Amanda Dean O.B.S. Dept.4. Amanda Dean O.B.S. Dept. 5. Linda Carabin 3 rd West Medical5. Linda Carabin 3 rd West Medical 6. Ruth O’Connell 3 rd East Telemetry6. Ruth O’Connell 3 rd East Telemetry

4. What is Medication Reconciliation ? M.R. is a process designed to prevent medication errors at patient transition points.M.R. is a process designed to prevent medication errors at patient transition points. It includes :It includes : A) Creating the most complete and accurate list or Best Possible Medication History of all home medications for each patient. A) Creating the most complete and accurate list or Best Possible Medication History of all home medications for each patient. B) Using that list when writing medication orders. B) Using that list when writing medication orders. C) Comparing the list against the physician’s admission, transfer, and /or discharge orders; identifying and bringing any discrepancies to the attention of the physician; and, if appropriate, making changes to the orders ensuring the changes are documented. C) Comparing the list against the physician’s admission, transfer, and /or discharge orders; identifying and bringing any discrepancies to the attention of the physician; and, if appropriate, making changes to the orders ensuring the changes are documented.

5. Why is Medication Reconciliation important ? 1. To prevent adverse drug events.1. To prevent adverse drug events. 2. To prevent medication errors at2. To prevent medication errors at patient transition points. patient transition points. a) Admission a) Admission b) Transfer b) Transfer c) Discharge c) Discharge 3. It is a (ROP) Required Organizational Practice 3. It is a (ROP) Required Organizational Practice ( It is a required practice for all ( It is a required practice for all personnel to perform when personnel to perform when admitting, transferring, and admitting, transferring, and discharging patients in the discharging patients in the health care system) health care system) Accreditation (Qmentum) Accreditation (Qmentum)

6. What is a “Best Possible Medication History (BPMH)” 1. Please refer to the form called “Best Possible1. Please refer to the form called “Best Possible Medication History on Admission”. Medication History on Admission”. 2.This is a list of medication that is obtained2.This is a list of medication that is obtained after interviewing the patient. after interviewing the patient. 3.This list is made up of all the medication the patient3.This list is made up of all the medication the patient is presently taking and how they take each of them, is presently taking and how they take each of them, “as stated by the patient”. “as stated by the patient”. 4. This list includes a review of the patients4. This list includes a review of the patients medication with their Community’s Pharmacy. medication with their Community’s Pharmacy.

7. Patient interviews are a critical process for medication reconciliation Without the patient interview, a vital source of information in the forming of a medication list will cause you not to be able to complete the medication reconciliation process.Without the patient interview, a vital source of information in the forming of a medication list will cause you not to be able to complete the medication reconciliation process. The patient, in most instances, is the one person who knows exactly how, when, and if he or she is taking prescribed medications.The patient, in most instances, is the one person who knows exactly how, when, and if he or she is taking prescribed medications. The information the patient offers goes far beyond confirming an established medication list.The information the patient offers goes far beyond confirming an established medication list.

8. Best Possible Medication History Form At The Glace Bay and New Waterford Site

9. The medication reconciliation process is considered complete when all discrepancies have been resolved (reconciled) and all components of the form have been completed.The medication reconciliation process is considered complete when all discrepancies have been resolved (reconciled) and all components of the form have been completed.

10. Patient and family having the medication reconciled

11. Medication Reconciliation on Transfer Med. Rec. is done on every transfer of a patient from unit to unit and site to site.Med. Rec. is done on every transfer of a patient from unit to unit and site to site. At the Glace Bay/NW site if a patient is less then 24 hrs in the Emergency department a nurse to nurse review of the BPMH on admission is done and signed by both parties (the ER nurse with the receiving unit nurse).At the Glace Bay/NW site if a patient is less then 24 hrs in the Emergency department a nurse to nurse review of the BPMH on admission is done and signed by both parties (the ER nurse with the receiving unit nurse). If the patient is greater then 24 hrs in the emergency department a “new” sheet (transfer) is to be completed by the receiving unit nursing personnel.If the patient is greater then 24 hrs in the emergency department a “new” sheet (transfer) is to be completed by the receiving unit nursing personnel. When a transfer occurs between 3 rd West and 3 rd South Med. Rec. is to be completed by both nurses (transferring nurse & receiving nurse) performing a medication review, to reconcile any discrepancies.When a transfer occurs between 3 rd West and 3 rd South Med. Rec. is to be completed by both nurses (transferring nurse & receiving nurse) performing a medication review, to reconcile any discrepancies.

12. Transfer Form (Completed by Receiving Unit Nursing Personnel)

13. Medication Reconciliation on Discharge At the Glace Bay/NW site when a patient is discharged, they will receive a copy of the discharge form that has been signed and reviewed by the discharging physician.At the Glace Bay/NW site when a patient is discharged, they will receive a copy of the discharge form that has been signed and reviewed by the discharging physician. That same form will be faxed to the patients Community pharmacy and it will serve as the patients medication profile on discharge.That same form will be faxed to the patients Community pharmacy and it will serve as the patients medication profile on discharge. Nursing home patients and those going to LTC, a discharge form will be faxed.Nursing home patients and those going to LTC, a discharge form will be faxed. Please remember to clarify the patient’s Community pharmacy.Please remember to clarify the patient’s Community pharmacy. Obtain a consent from the patient to have this information sent off to their Community Pharmacy.Obtain a consent from the patient to have this information sent off to their Community Pharmacy. The patient on discharge will have the same information as the Community Pharmacy, Physician, and it will become a part of the patients record.The patient on discharge will have the same information as the Community Pharmacy, Physician, and it will become a part of the patients record.

14. Patient Medication Profile/ Discharge Form At the Glace Bay Site

15. We see this many times with our patients on admission. “I take that blue and red one”, “I think its for my heart”????

16. Summary Steps to Medication Reconciliation: Steps to Medication Reconciliation: 1. Review the chart ( Doctors1. Review the chart ( Doctors orders) orders) 2. Interview the patient/ family2. Interview the patient/ family 3. Review the “list/medication3. Review the “list/medication bottles” bottles” 4. Contact Community Pharmacy4. Contact Community Pharmacy 5. If a discrepancy– return to5. If a discrepancy– return to interview the patient. interview the patient.

17. Any Questions ?

18. Case Scenario Patient M 73 year old female, arrived at the E.R. c/o anterior chest pain.Patient M 73 year old female, arrived at the E.R. c/o anterior chest pain. AnxiousAnxious Family not present.Family not present. No medication bottles on arrivalNo medication bottles on arrival Chest pain has since resolved and pt is now stable. Medication Reconciliation interview can now take place….Chest pain has since resolved and pt is now stable. Medication Reconciliation interview can now take place….

19. Best Possible Medication History Tamoxifen 10mg twice dailyTamoxifen 10mg twice daily Vitamin B12 1000mcg dailyVitamin B12 1000mcg daily Synthroid.025 mg once dailySynthroid.025 mg once daily Apo-hydro 25 mg ½ tab dailyApo-hydro 25 mg ½ tab daily Alendonate FC 70 mg once weeklyAlendonate FC 70 mg once weekly Betnovate cream to groins twice dailyBetnovate cream to groins twice daily Crestor 10 mg once dailyCrestor 10 mg once daily ASA 81 mg once dailyASA 81 mg once daily

20. BPMH Con’t Vit D 1000 IU once dailyVit D 1000 IU once daily Calcium 650 mg once dailyCalcium 650 mg once daily Ibuprofen 200 mg two tablets PRNIbuprofen 200 mg two tablets PRN Garlic Tablet two three times dailyGarlic Tablet two three times daily Garamycin eye gtts one drop both eyes four times a dayGaramycin eye gtts one drop both eyes four times a day Amytriptyline 10 mg one tab at bedtime-no longer taking.Amytriptyline 10 mg one tab at bedtime-no longer taking. Zantac 150 mg- states taking prnZantac 150 mg- states taking prn

21. Best Possible Medication History Tamoxifen 10 mg twice dailyTamoxifen 10 mg twice daily Vit B12 1000 mcg once dailyVit B12 1000 mcg once daily Synthroid.025 mg once dailySynthroid.025 mg once daily Apo-hydro 25 mg ½ tab dailyApo-hydro 25 mg ½ tab daily Alendonate FC 70 mg once weeklyAlendonate FC 70 mg once weekly Betnovate cream to left elbow twice dailyBetnovate cream to left elbow twice daily Zantac 150 mg-prnZantac 150 mg-prn Crestor 10 mg once daily ASA 81 mg once daily Vit D 1000 IU once daily Calcium 650 mg once daily Ibuprofen 200 mg two tablets PRN Garlic Tablet two three times daily Garamycin eye gtts one drop both eyes four times a day Elavil 10 mg hs-not taking

22. Meds & more Meds

23. Research has shown that poor communication of medication information at transition points is responsible for medication errors and adverse events.

24. Thank you