2. © Institute for Safe Medication Practices Canada 2012® Jump into MedRec: Improving BPMH Quality Across the Continuum of Care An interprofessional education collaboration by TBRHSC clinical nurse specialists, interprofessional educators, and pharmacists. Through collaboration we are advancing patient safety at TBRHSC!

3. © Institute for Safe Medication Practices Canada 2012® Welcome to the BPMH Training Module! Estimated duration to complete module: 35 minutes Please note the following: The BPMH training PowerPoint is to be completed prior to attending clinical placement at Thunder Bay Regional Health Sciences Centre. Review the “How to Guide for Nursing Staff” to access the Medication Reconciliation Module in Meditech. Please ensure your volume is turned up. While the majority of the module is narrated, you can read the slides if sound is not available.

4. © Institute for Safe Medication Practices Canada 2012® Objectives At the end of the session participants will: Learn how to obtain a BPMH using a systematic process. Learn how to identify and document discrepancies between sources of information. Apply the knowledge, tools, and resources offered during the session to their own healthcare environment.

5. © Institute for Safe Medication Practices Canada 2012® A Grandfather An 83 year-old resident of a long-term care facility was transferred to hospital for management of dehydration. While in hospital, the following medication was sent to pharmacy “K-Lor 20 mEq, 2 packs PO now and repeat in 4 hours”. The order was entered and processed and the notation DC appeared on the profile.

6. © Institute for Safe Medication Practices Canada 2012® Computer Profile Discontinue Medication Reconciliation and Medication Review: Complementary Processes for Medication Safety in Long-Term Care. ISMP Canada Safety Bulletin 2007; 7(9).

7. © Institute for Safe Medication Practices Canada 2012® Unfortunately... Two days later, the resident was discharged back to the LTC facility. Potassium chloride 40 mEq PO Q4H was included in the medication orders and administered for the next 17 days. At that time, the resident was re-admitted to hospital with hyperkalemia (potassium level > 9 mmol/L), dehydration, and subsequently died.

8. © Institute for Safe Medication Practices Canada 2012® What is Medication Reconciliation? Goal: Prevent adverse drug events by implementing a medication reconciliation process upon admission, transfer, and discharge. Health-care providers work together with patients/caregivers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care.

9. © Institute for Safe Medication Practices Canada 2012® What is Medication Reconciliation? It involves: Completion of a thorough comprehensive BPMH. Identifying and documenting discrepancies. Resolving the discrepancies, and communicating all medication information to the next care provider.

10. © Institute for Safe Medication Practices Canada 2012® What is Best Possible Medication History (BPMH) A Best Possible Medication History (BPMH) is a medication history obtained by a clinician which includes a thorough history of all regular medication use (prescribed and non-prescribed), using a number of different sources of information. The BPMH is different and more comprehensive than a routine primary medication history. Because... it’s the BEST you can do with the information you can gather at the time. Why is called the ‘Best Possible’?

11. © Institute for Safe Medication Practices Canada 2012® Why do we need to Implement Medication Reconciliation? Accreditation Canada has identified medication reconciliation as a required organization practice (ROP). Thunder Bay Regional Health Sciences Centre must implement the medication reconciliation process in order to meet Accreditation Canada requirements for 2014.

12. © Institute for Safe Medication Practices Canada 2012® TBRHSC Case Example #1 Patient admitted to a medical service at TBRHSC. Change in condition requiring admission to Critical Care. On transfer to Critical Care, patient’s home phenytoin (for seizure disorder) was accidentally not prescribed. A few days later when patient was transferred back to the medical service, phenytoin was still not prescribed. Several days later, patient had a seizure due to omission of home phenytoin medication.

13. © Institute for Safe Medication Practices Canada 2012® Who Can Do A BPMH? Prescribers/physicians, nurses, midwives, pharmacists, pharmacy technicians, and other healthcare professionals...... who have been formally trained, who follow a systematic process, who are conscientious, responsible, and accountable...... in partnership with the patient/resident/client and family/caregiver.

14. © Institute for Safe Medication Practices Canada 2012® Clinical Responsibility It is not about changing your scope of practice. Responsibility for assessing the clinical appropriateness of each medication continues to be multidisciplinary. If you see something that concerns you, communicate/document your concerns to the prescriber.

15. © Institute for Safe Medication Practices Canada 2012® When to do the BPMH The nurse will obtain the BPMH within 24-hours of admission to an inpatient unit. Some departments have different timeframes to obtain the BPMH: Preadmission clinic nurse will obtain the BPMH at the pre-operative visit. Critical care 48-72 hr. (often patients are intubated). Emergency Department 12-hr. of admission

16. © Institute for Safe Medication Practices Canada 2012® How to Complete a Thorough BPMH 1. Interview 2. Compare 3. Identify 4. Document any discrepancies

17. © Institute for Safe Medication Practices Canada 2012® Step 1: BPMH Interview: A Systematic Process Talk and listen to patient/family/caregiver: Ensure environment conducive to interview. Ask for current medication list. Consider current actual medication use – not what they were prescribed. Ask open ended questions i.e., “how do you take this?”

18. © Institute for Safe Medication Practices Canada 2012® BPMH Interview: A Systematic Process (continued) Be proactive gather information ahead of time. Time commitment: goal 15 to 20 minutes. Prompt questions about all medications. Prompt questions about unique dosage forms. Use medical conditions as a trigger when possible. Ask if have taken antibiotics in past 3-months.

19. © Institute for Safe Medication Practices Canada 2012® BPMH Interview: A Systematic Process (continued) Obtain community pharmacy information. Ask about: Prescriptions (patches, creams, eye drops, inhalers) Over-the-counter (OTC) medications Herbal and other natural remedies Vitamins and minerals Recreational drugs Samples Clinical trial medications. Don’t make assumptions. Use ‘head-to-toe’ review of systems approach Use the BPMH interview tool.

20. © Institute for Safe Medication Practices Canada 2012® Step 2: BPMH Compare Sources of Information BPMH Compare Identify & document discrepancies between the sources of information Multiple sources Medication vials Blister packs Community pharmacy list Hospital discharge summary Long-term care MAR Electronic records Patient and Family Interview When and where possible Determine what the patient is ACTUALLY taking.

21. © Institute for Safe Medication Practices Canada 2012® Sources of Information Patient (recall) Family/caregiver (recall) Medication vials Bubble pack/dosette Discharge orders from other facility (including MAR) Patient own or previous medication list Community pharmacy Ontario Drug Benefits Drug Profile viewer (ODB DPV) Other?

22. © Institute for Safe Medication Practices Canada 2012® Medication Information From Multiple Sources All sources of information are NOT created equally. START with the most recent sources of info. Know the limitations of your sources.

23. © Institute for Safe Medication Practices Canada 2012® Community Pharmacy Profile Ask the patient if they use more than one pharmacy. When calling the pharmacy verify you have the correct patient using another piece of information besides the name (address, date-of-birth). Confirm with the patient if there any other medications they are taking (prescriptions, PRNs, over-the-counter [OTCs], herbals, vitamins, etc.). Confirm if they are taking the medications differently than prescribed. Confirm the allergies that the community pharmacy has on record.

24. © Institute for Safe Medication Practices Canada 2012® Medication Vials/Blister Packs Check the patient’s name on the vial. Check the date on the vial. Open the vials and make sure what is in the vial matches the label. Ask the patient how they are taking the medication – compare it to the instructions on the vial. Check the patient’s name on the blister pack. Check the date on the blister pack (determine if any changes have been made to the patient’s medications since the blister pack has been filled). Do not assume patient is taking all of the medications in the blister pack. Ask about medications that cannot fit inside the pack, e.g., puffers, patches, eye/ear drops, injectables, etc. Ask about PRN medications.

25. © Institute for Safe Medication Practices Canada 2012® Step 3: What If Two Sources Of Information Don’t Match? Verify medications using at least two sources Identify the discrepancies: Only one of them is what is actually happening. Find out as much as you can from the sources of information, call pharmacy, start-stop dates – investigate further. Document the discrepancies Comments section is used for communicating these types of discrepancies.

26. © Institute for Safe Medication Practices Canada 2012® Step 4: Document BPMH to… Ensure that a standardized, comprehensive process is used. Documented information = better patient outcomes. Serves as historical reference.

27. © Institute for Safe Medication Practices Canada 2012® Challenges in Obtaining a BPMH  Belief – physician has information  Unfamiliar with medications and names  Difficulty re-calling  Medicated patients (sedated, confused)  Disease affects mental status  Language barrier  Hearing impairment  Elderly patients  Caregiver administers or sets up medications  Medication vials or list unavailable  If patient can not remember a medication or if clarification is needed:  Get a description of the medication from the patient or family member (form, strength, size, shape, colour, markings)  Contact family member that could possibly bring in the medication or read it over the phone  Call the patient’s pharmacy  Review previous medical records

28. © Institute for Safe Medication Practices Canada 2012® Helpful Documentation Tips Pay attention to high alert drugs (e.g. coumadins, insulin, opiates, psychotropics, etc.). Liquids - record the concentration of the liquid (mg/mL). Don’t forget injectables (vitamin B 12, methotrexate, psychotropics, etc.).

29. © Institute for Safe Medication Practices Canada 2012® Helpful Documentation Tips Ensure the proper formulation of the medication is ordered, long acting vs. short acting (CR, XR, ER, LA). Be mindful that certain medications have to be administered at exact times (Sinemet® [carbiopa-levodopa]). Be aware of generic/trade names, autosubstitutions. Do not use dangerous abbreviations.

30. © Institute for Safe Medication Practices Canada 2012® Best Possible Medication History …a systematic process, …the cornerstone of medication reconciliation, …includes identifying and documenting discrepancies …uses at least two sources of information to create a Best Possible Medication History

31. © Institute for Safe Medication Practices Canada 2012® Admission Medication Reconciliation Form Once admission orders are processed and BPMH is obtained and documented, the Admission Medication Reconciliation form will be printed and put on the chart by nurse/pharmacist. This form will contain the patients home medications in the left hand column and medications prescribed while in hospital in the right hand column

32. © Institute for Safe Medication Practices Canada 2012® 1.The patient will come to Surgical Day Care with a Pre-op package entitled “Home Medication Post- op Order Form” which lists the patients home medications. Home Medication Post-op Order Form 2.Post-operatively the surgeon will review each home medication and select “yes” for medications that are to be continued post-op and select “no” for medications not to be continued post-op. 3.For medications not to be continued post-op indicate reason in the medication section. 4.The form will be signed and dated by the surgeon and then faxed to the Pharmacy Department and put in the Physician Order section of the patient’s chart. Indicate reason for not continuing medication(s) post-op in this section.

33. © Institute for Safe Medication Practices Canada 2012® 1.The Intensivist will review the form “Medication Order for Patients Transferred Between Programs Within Facility ”. Medication Order for Patients Transferred Between Programs 2.The Intensivist will review each current medication and select “yes” for medication to be continued or “no” for medication that is not to be continued for the patient transferred to the ward. 3.For medications not to be continued upon transfer to the ward, indicate reason in the medication section. 4.The form will be signed and dated by the Intensivist and then faxed to the Pharmacy Department and put in the Physician Order section of the patient’s chart. Indicate reason for not continuing medication(s) post-op in this section.

34. © Institute for Safe Medication Practices Canada 2012® It involves: Completion of a thorough comprehensive BPMH. Identifying and documenting discrepancies. Resolving the discrepancies, and communicating all medication information to the next care provider. Please direct any questions to your clinical instructor. Medication Reconciliation - Review

35. © Institute for Safe Medication Practices Canada 2012® Thank-you!