1. Kara Jackson Clinical Pharmacy Technician Minneapolis, MN

2. Medication Reconciliation Flow Upon admission: patient/caregiver/etc. interviewed by pharmacy (technician or pharmacist) Med Recon Note entered into CPRS listing how patient actually takes medications (versus Rx direction) Physician uses Med Recon Note to order inpatient medications Clinical pharmacist uses Med Recon Note to reconcile inpatient orders (versus home medications) Identifies discrepancies or problems and clarifies with physician

3. 1. Patient Roster Assignment of PATIENTS to their corresponding Clinical pharmacists & by Medical team affiliation Vista: inpatient roster report to file Import into Excel® via text import wizard Excel®: able to sort by ward, patient name, RPh, medical team, etc…

4. Roster – Technician responsibilities (cont) Supply clinical pharmacists w/daily staffing schedule Identify patient “name alerts” Identify drugs that require special monitoring gentamicin, tobramycin, vancomycin, enoxaparin, warfarin, heparin, argatroban, phytonadione tab, phytonadione inj Provide copies to Pharmacy staff Maintain current medical resident/team assignments Residents rotate x 2 monthly (teaching hospital)

5. Daily Roster: Example NameWardBedTEAMClinical RPhAD RPhDrug Patient 2LT 2L108-1 SURGERY Inna Michellevanco Patient 2LV 2L120-2 SURGERY InnaMichelle Patient 2LG 2L132-1 SURGERY InnaMichelle Patient 2LT 2L118-3 SURGERYInnaMichellevanco Patient 2LS 2L128-4 SURGERYInnaMichelle Patient 2LS 2L104-1 SURGERYInnaMichellevanco Patient 3F 3F118-1 GOLDMaraMaryvanco Patient 3LS 3L135-1 V1MaraMaryheparin/warfarin Patient 3L 3L102-1 GOLDMaraMarywarfarin Patient 3LS 3L109-1 HOLDOVERMaraMary Patient 3L 3L134-1 HOLDOVERMaraMary

6. 2. Interviewing/Obtaining Medication History (Medicine Admits) After daily Rosters completed, 1 st order of day is to interview patients admitted overnight “Holdovers” = overnight admissions typically not interviewed by pharmacy yet Work with clinical pharmacists to get all “Holdover” interviews completed

7. 2. Interviewing/Obtaining Medication History - Medicine Admits (cont) New Admissions throughout the day VISTA report (L24): real time notification of admits Clinical technician monitors through the day Will assist clinical pharmacists with interviews if needed/available Emergency Room: check in to ER @ 1000, 1200, 1400 Communicate with ER Physicians – who are they admitting to hospital? Communicate with ER Pharmacist Communicate admits to clinical pharmacists Enter Med Recon Note in CPRS Update “MEDICINE Med Recon List” which department uses as a communication tool (Excel® spreadsheet)

8. Medicine Med Recon List

9. 3. Surgery Med Recon Anticipate all Surgical patients who will be admitted to hospital (post-op) Vista: search by appointment title and other sources Add patients to : “SURGERY Med Recon List” utilized as a communication tool (Excel® spreadsheet) Begin calling patients 3-4 day prior to surgery Enter Med Recon Note in CPRS include pre-op medication instructions MD added as additional signer on day of surgery

10. Schedule of Operations @ 1430 daily: Surgical Service sends copy of “Schedule of Operations” for the following day Check schedule for last minute surgical add-on’s Anticipated admits listed with post-op disposition: WARD &/or 2LOBS Add names to “SURGERY Med Recon List” Set up document(s) & call patient Communicate to Access Clinic technician

11. Access Clinic Technicians Technicians available as “back-up” Available to make phone calls/interview 2KOBS patients after 1530 Communicate evening duties via “SURGERY Med Recon List” &/or verbal instruction Provide coverage in [my] absence (SURGERY Med Recon ONLY) (trial): assist evening AD with Medicine admits

12. In Conclusion: Summary of Responsibilities: Organize and maintain Roster(s): assign pharmacists to their patients (by team & MD) Organize communication tools Roster(s), Med Recon Lists(s), L24 Interview Medicine admits Interview Surgery admits Anticipate admits, set up documents, & call 3-4 days in advance Provide guidance to Access Clinic technicians