1. Medication Reconciliation Patty Grunwald, PharmD, BCPS Clinical Pharmacy Coordinator Frederick Memorial Hospital, Frederick, Maryland

2. JCAHO 2006 National Patient Safety Goal Goal 8Accurately and completely reconcile medications across the continuum of care. 8AImplement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. 8AImplement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. 8BA complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. 8BA complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

3. Steps in Reconciliation Process Develop complete and accurate medication list Develop complete and accurate medication list Compare (reconcile) the listed medications with any new orders Compare (reconcile) the listed medications with any new orders Update the list as orders change Update the list as orders change Communicate the updated list to the next provider of care. Communicate the updated list to the next provider of care.

4. When Should Reconciliation Occur? Whenever the organization… Whenever the organization… “… refers or transfers a patient to another setting, service, practitioner, or level of care within or outside the organization.” “… refers or transfers a patient to another setting, service, practitioner, or level of care within or outside the organization.” At a minimum… At a minimum… Any time the organization requires orders be rewritten Any time the Patient changes service, setting, provider or level of care and new medication orders are written For transitions not involving new medications or rewriting of orders, the organization determines whether reconciliation must occur. For transitions not involving new medications or rewriting of orders, the organization determines whether reconciliation must occur.

5. Roadblocks Medical staff acceptance Medical staff acceptance Overcoming concerns related to the accuracy of solicited medication list Overcoming concerns related to the accuracy of solicited medication list Ownership for medication oversight Ownership for medication oversight “My patient-type is very unique” “My patient-type is very unique” “You just don’t understand” “You just don’t understand” Consistency among residents and physician extenders Consistency among residents and physician extenders Communication among consultants Communication among consultants

6. Medication Reconciliation: Who’s Responsibility is it?

7. Problems With Getting Accurate List Patient brings in incorrect list Patient brings in incorrect list Patient does not take what is marked on the bottle Patient does not take what is marked on the bottle Patient does not know what is on and family, pharmacy not available Patient does not know what is on and family, pharmacy not available Wrong name of med on ED sheet Wrong name of med on ED sheet Med bottles don’t jive with what the patient says Med bottles don’t jive with what the patient says Patient is unable to tell you. No family available. MD on call does not know either. Patient is unable to tell you. No family available. MD on call does not know either. Can’t call the pharmacy “after hours” Can’t call the pharmacy “after hours”

8. FMH Process A work in progress A work in progress Three domains: Three domains: –Admission –Transfer/re-order post-op –Discharge

9. FMH Form

10. FMH Form (con’t)

13. Medication Reconciliation Results

14. Number of Patients

15. Admissions Unit Pilot Begins January 16, 2006 Begins January 16, 2006 Uses current workflow Uses current workflow Nurse will print form right before patient leaves unit Nurse will print form right before patient leaves unit MD to review/sign within 24 hrs of admission MD to review/sign within 24 hrs of admission Expand to SDSS in January 2006 Expand to SDSS in January 2006

16. Plan for Transfers Work in progress Work in progress Revise current transfer/reorder list to have the same information as medication reconciliation form Revise current transfer/reorder list to have the same information as medication reconciliation form Will decrease physician time in reordering medications post-op Will decrease physician time in reordering medications post-op

17. Plan for Discharges Create a form based on the admission reconciliation form Create a form based on the admission reconciliation form Include lay language on how to take medication Include lay language on how to take medication Include statement to notify physicians of interchanges Include statement to notify physicians of interchanges

18. Evaluation Process 100% review during pilot 100% review during pilot Thereafter, 25 cases per area per month Thereafter, 25 cases per area per month Data collected: Data collected: –Number possible reconciliations –Percent charts with form –Percent with signed forms –Number home medications restarted –Number hospital medications DC’d

19. Contact Information Phone: 240-566-3797 Phone: 240-566-3797 E-mail: pgrunwald@fmh.org E-mail: pgrunwald@fmh.org