1. Medication Reconciliation 2013

2. 2 Medication Reconciliation What is medication reconciliation? Active decision about medication requirements during a transition of care after reviewing home medications for possible drug-drug interactions, drug duplications, dosing errors, or omissions[1] Adding a new medication Stopping an existing medication Changing an existing medication (dose and/or frequency) Medication reconciliation should be considered at major transitions of patient care Ambulatory facility/ED visit Admission to hospital/other facility Transfer to a different level of care in same facility Discharge from hospital/other facility

3. 3 Medication Reconciliation Facts Why is medication reconciliation important? 2,022 reports of medication reconciliation errors from September 2004 to July 2005 reported to US Pharmacopeia (USP)[2] 22% occur at admission 66% occur at transition in level of care 12% occur at discharge 1.5 million preventable adverse drug events (ADEs) occur annually as a result of medication errors $3 billion per year cost associated with preventable ADEs 50% of all hospital-related medication errors and 20% of all ADEs result from poor communication at the transitions of care[3,4] ADEs result in 2.5% of ED visits for all unintentional injuries and 6.7% of those leading to hospitalization[5]

4. 4 Medication Reconciliation Why is medication reconciliation required? Quality of care: reduce adverse events lower cost Professionalism: prevent errors in care Regulatory: The Joint Commission requirement

5. 5 UCI Med Reconciliation Process Obtain an accurate home medication list at start of patient encounter by Physician/NP/PA Nurse Pharmacist MA Use various tools in Quest for viewing/updating home medication list and inpatient medication list for reconciliation at major transitions of care

6. 6 UCI Med Reconciliation Process What features does each tool have for medication list? OMR Rx Writer OR Manager Clinical Summary Tab Orders Tab (ORM) Med Reconciliation View Pharmacy View View home medications View inpatient medications View home medications Update home medications View home medications Update home medications Rx new home medications View home medications Update home medications Rx new home medications Order inpatient medications View inpatient medications Manage inpatient medications Order inpatient medications Order icon

7. 7 UCI Med Reconciliation Process Select your primary role: Adult patient care Neonatal patient care

8. 8 UCI Process - Adult Patient Care Admission to hospitalObtain/document medication Hx Everyone has a role Reconcile home/inpatient medication Physician/NP/PA gets medication Hx from patient and Quest tools and documents medication list in H&P and/or OMR Nurse gets medication Hx from patient, H&P, and Quest tools and documents medication list in OMR with status of review Physician/NP/PA reconciles home medications with inpatient orders in Order Reconciliation Manager (ORM) within 24 h of admission

9. 9 Documenting Home Medications Updating the home medication list in Quest tools maintains a consistent list of home medications that can be referenced in the Clinical Summary Medication Reconciliation view Status of home medication list is indicated

10. 10 New Quest Tools - O M R +Add home medicationUpdate status of home medication list: taking, not taking, unknown, or incomplete Mark as reviewed ? ? Needs follow-up for incomplete info No longer taking Home Med Review status Edit medication dose or frequency Edit Pharmacy info

11. 11 New Quest Tools - O R M Select here for admission reconciliation. Status of medication reconciliation displays

12. 12 New Quest Tools - O R M =Home medication list (in OMR) not done =Home medication list (in OMR) incomplete =Home medication list (in OMR) complete Only works if home medication list was complete and all medications are reconciled; otherwise, it will save as incomplete Floating menu arrow + If home medication list needs editing, it can be done by using +Enter function, launching OMR, or editing each drug individually

13. 13 Admission Reconciliation [Expanded View] Stop/hold on admission= Floating menu arrow Reconciliation options for home medications appear after hovering over floating menu arrow (see previous slide) Convert to inpatient order= Change dose/frequency or alternative drug

14. 14 Admission Reconciliation If there is an existing inpatient order, it will match up with closest home medication for reconciliation Home MedicationsInpatient Medications

15. 15 Admission Reconciliation Home MedicationsInpatient Medications Patient was no longer taking this drug, so it becomes crossed out Held on admission Continued as inpatient order All home medications reconciled

16. 16 Admission Reconciliation Enter additional admission medications

17. 17 Discharge Reconciliation

18. 18 Discharge Reconciliation Use Discharge Note to launch discharge reconciliation (ORM)

19. 19 Discharge Reconciliation Launch discharge medication reconciliation (ORM) from new Discharge Note

20. 20 New Quest Tools - ORM Discharge medication reconciliation Select here for discharge reconciliation. Status of medication reconciliation displays

21. 21 Discharge Reconciliation If home medications prior to admission were incomplete, add or edit here After discharge reconciliation, the new home medication list at discharge will display on right side column ITEMS TO RECONCILE= active inpatient and pre-admission medications e-Rx new discharge prescriptions here

22. 22 Discharge Reconciliation There are also quick action buttons for each medication in Discharge Reconciliation that are only enabled if there is a match in Prescription Writer for quick prescription: If not enabled, you can still use the menu options to reconcile or prescribe: Continue at home w/o Rx quick discharge e-Rx Not required or stop

23. 23 Discharge Reconciliation Home medication that was converted to inpatient order Home medication that was not continued as inpatient order Discharge reconciliation options for pre-admission home medication Discharge reconciliation options for inpatient medication

24. 24 New Quest Tools - ORM Choose expanded view in Format Layout to see all drugs Pill indicates inpatient medication House/pill = home medication Indicates variations of same drug (2)

25. 25 New Quest Tools - ORM Choose expanded view in Format Layout to see all drugs Inpatient medication Both versions expanded House/pill = home medication

26. 26 Discharge Reconciliation Discharge medication reconciliation actions: Tylenol was not ordered as inpatient drug but resumed at discharge Oral Dilantin prior to admission was converted to IV as inpatient order and then back to oral with e-Rx at discharge IV Dilantin ordered as inpatient was not continued at discharge Pre-admission oral Dilantin is crossed off since new e-Rx created at discharge Inpatient IV Dilantin crossed off since not continued at discharge

27. 27 Discharge Reconciliation Add discharge medication instructions in note after ORM is complete Required for Discharge Instructions to print. Will only auto- check if ORM is complete; otherwise, selection will clear Continue Home Medications Tylenol 325 mg, 2 tablets every 4 hours as needed for pain or fever New Prescription Dilantin extended release 30 mg, 1 capsule at bedtime Sent to CVS, Orange (714) 555-5500 Click to update discharge medication list in Discharge Note Instruction Categories: Continue Home Medications These Home Medications Are Not Changed These Home Medications Are Changed New Prescription(s) Stop These Home Medications

28. Discharge to Another Facility Discharge to another facility does not require ORM 28 Select to open active inpatient orders Required for Discharge Instructions to print

29. Printing Discharge Medications Patient Discharge Instructions will not print until: the status of medication reconciliation is complete and verified by Pharmacy for patients going to home, B&C, AL, etc. or Discharge Note indicates that transfer orders are complete for patients discharging to another facility (SNF, LTAC, or other acute care setting). New prescriptions or any updates to the medication list after the status of medication reconciliation is completed will cause it to become incomplete again Discharge medication reconciliation needs to be re-done for any new Rx Discharge medication list needs to be refreshed in Discharge Note 29

30. 30 Re-do Discharge Reconciliation A reconciliation can be reset to incomplete if saved in error or additional information was received. Re-launch ORM: 1) Select View/Maintain History tab 2) Select Discharge Reconciliation Type 3) Click Set to Incomplete and return to Reconciliation Orders tab

31. Admission Medication History: You can update the home medication list via OMR while in the H&P note and pull that list into your note. Indicates the home medication list, collected by the nurse, is complete Medication Reconciliation: Admission reconciliation is to be done within 24 hours of admit Remember to hover over the medication list to use the floating menu arrow to select reconciliation options 31 Summary of Key Points

32. 32 Discharge: Discharge medication reconciliation (ORM) automatically updates Prescription Writer and the medication list on the patients Discharge Instructions In the Discharge Note for patients transferred to another facility, you are directed to review and select appropriate current orders to be continued. This constitutes the Discharge Order/Treatment Plan that includes medications Medication reconciliation (ORM) is not done on these types of discharges Summary of Key Points

33. 33 Discharge (cont.): New prescriptions or edits in Prescription Writer will reset the discharge medication reconciliation to an incomplete status. Return to the Discharge Note, Launch medication reconciliation (ORM) and complete it, Refresh medication list in the Discharge Note Nursing will not be able to discharge the patient until medication reconciliation and Pharmacy review is complete. Discharge Instructions will not print until reconciliation is complete Summary of Key Points

34. 34 Medication Reconciliation - Adult Please make selection: End training Review Adult patient care admission medication reconciliation Review Adult patient care discharge medication reconciliation Neonatal patient care

35. 35 UCI Process - Neonatal Care Admission to hospitalObtain/document medication Hx Everyone has a role Reconcile home/inpatient medication If transfer, physician/NP/PA gets medication Hx from family and/or transfer records and documents medication list in H&P and/or OMR If admitted from home, nurse gets medication Hx from family, H&P, and QUEST tools and documents medication list in OMR with status of review Physician/NP/PA uses medication Hx to order inpatient medications

36. 36 Documenting Home Medications Updating the home medication list in Quest tools maintains a consistent list of home medications that can be referenced in the Clinical Summary Medication Reconciliation view Status of home medication list is indicated

37. 37 New Quest Tools - O M R +Add home medicationUpdate status of home medication list: taking, not taking, unknown, or incomplete Mark as reviewed ? ? Needs follow-up for incomplete info No longer taking Home Med Review status Edit medication dose or frequency Edit Pharmacy info

38. 38 Discharge Medication Reconciliation - O R M Launch discharge medication reconciliation Select here for discharge reconciliation. Status of medication reconciliation displays

39. 39 Discharge Reconciliation If home medications prior to admission were incomplete, add or edit here After discharge reconciliation, the new home medication list at discharge will display on right side column ITEMS TO RECONCILE= active inpatient and pre-admission medications e-Rx new discharge prescriptions here

40. 40 Discharge Reconciliation There are also quick action buttons for each medication in Discharge Reconciliation that are only enabled if there is a match in Prescription Writer for quick prescription: If not enabled, you can still use the menu options to reconcile or prescribe: Continue at home w/o Rx quick discharge e-Rx Not required or stop

41. 41 Discharge Reconciliation Home medication that was converted to inpatient order Home medication that was not continued as inpatient order Discharge reconciliation options for pre-admission home medication Discharge reconciliation options for inpatient medication

42. 42 New Quest Tools - ORM Choose expanded view in Format Layout to see all drugs Pill indicates inpatient medication House/pill = home medication Indicates variations of same drug (2)

43. 43 New Quest Tools - ORM Choose expanded view in Format Layout to see all drugs Inpatient medication Both versions expanded House/pill = home medication

44. 44 Discharge Reconciliation Discharge medication reconciliation actions: Tylenol was not ordered as inpatient drug but resumed at discharge Oral Dilantin prior to admission was converted to IV as inpatient order and then back to oral with e-Rx at discharge IV Dilantin ordered as inpatient was not continued at discharge Pre-admission oral Dilantin is crossed off since new e-Rx created at discharge Inpatient IV Dilantin crossed off since not continued at discharge

45. 45 Re-do Discharge Reconciliation A reconciliation can be reset to incomplete if saved in error or additional information was received. Re-launch ORM: 1) Select View/Maintain History tab 2) Select Discharge Reconciliation Type 3) Click Set to Incomplete and return to Reconciliation Orders tab

46. 46 Medication Reconciliation - Neonatal Please make selection: End training Review Adult patient care admission medication reconciliation Review Adult patient care discharge medication reconciliation Review Neonatal patient care

47. 47 References [1] Pentecost MJ. "Improving health care quality: current concepts," Permanente Journal, 2007 Winter; 11(1): 75-8. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3061389/. Accessed May 13, 2013.www.ncbi.nlm.nih.gov/pmc/articles/PMC3061389/ [2] The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alert. Issue 35. January 25, 2006. Available at: http://www. jointcommission.org/assets/1/18/SEA_35.PDF. Accessed May 13, 2013.http://www. jointcommission.org/assets/1/18/SEA_35.PDF [3] Institute for Healthcare Improvement. 5 Million Lives: Preventing Adverse Drug Events (Medication Reconciliation): How-to Guide. Available at: http://www.ihi.org/IHI/Programs/Campaign/ADEsMedReconciliation.htm. Published Oct. 1, 2008. Accessed May 13, 2013. http://www.ihi.org/IHI/Programs/Campaign/ADEsMedReconciliation.htm [4] The Joint Commission. 2011 National Patient Safety Goals. Available at: http://www.jointcommission.org/assets/1/6/NPSG_EPs_Scoring_ HAP_20110706.pdf. Accessed May 13, 2013. http://www.jointcommission.org/assets/1/6/NPSG_EPs_Scoring_ HAP_20110706.pdf [5] Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events, JAMA, 2006; 296: 1858-66.