1. Prescriber Education
Medication Reconciliation Patient Safety Initiative

2. Why Med Rec? It is a patient safety initiative
Reduction of adverse events at key transitions of care (adm, transfer, disch)
One of the WHO top 5 patient safety initiatives²
Structured communication process that formalizes what we already do
Required for Accreditation
HC professionals partner with clients, families and caregivers for accurate and complete transfer of medication information¹
At the monthly management meeting of a large urban hospital, the head of patient safety announces: “We had a critical incident last week. A patient was readmitted two days after discharge with severe hypoglycemia. The treating team discharged the patient on a new insulin regimen without realizing that the patient also had insulin 30/70 at home. The patient continued to take her previous regimen as well as the new one, and was found unresponsive by her husband. She’s in the ICU and probably will have permanent neurological deficits.”
After various sighs and exclamations from around the table, the chief medical officer asks, incredulously, “Why didn’t this get picked up?” Before anyone can answer, the executive adds: “We had that other case six months ago in which a patient was discharged without restarting his warfarin, and he ended up having a stroke.” Adapted from: Fernandez O, Shojania K. (2012). Medication Reconciliation in the Hospital. What, why, where, when, who and how? Healthcare Quarterly Vol. 15 Special Issue 2012.
¹Accreditation Canada ROP
²World Health Organization

3. Admission Gleason et al (2010). MATCH study. Vira et al (2006).
85% med errors originate in medication histories, almost half were omissions
Risk Factors (age, #meds). (J Gen Int Med)
Vira et al (2006).
60% admitted pts had unintended discrepancies.
18% clinically significant
75% of these were intercepted by MedRec before pts suffered harm (Quality and safety in healthcare).

4. Discharge Intervention (MedRec) vs. control groups
33.5% medication discrepancies at discharge with MedRec
59.6% in control group (Walker et al, 2009 Arch Int Med)
Impact of a Pharmacist-Facilitated Hospital Discharge Program:  A Quasi-Experimental StudyArch Intern Med. 2009;169(21):

5. How does it work? BPMH Reconcile Document Review at transfer
MedRec at Discharge
Audit

6. Admission
Best Possible Medication History (BPMH) is the cornerstone of the MedRec admission process.
Home medication history
Reference point for clinical decisions to continue, discontinue or modify home medications during key transitions of care
Medication orders on admission
(once reconciled and signed by prescriber)
Ideally completed within 24h of admission
A BPMH may be completed prior to, or alongside, all other admission orders being written (Proactive/Prospective Model) or
After initial admission orders have been written (Retroactive/Retrospective Model).

7. BPMH Sources used to obtain history Date/Time the history completed
All prescribed home
Medications [including
Over-the-counter (OTC) medications
if they were PRESCRIBED to pt.]
Self-prescribed
Medications – (for information purposes only)
Additional Comments (information purposes only)
Reconciliation section
(Prescriber Use Only)
Prescriber signs & includes date and time of reconciliation
Page #s
If prescriber would like to order any of the patient’s self-prescribed medications, they must do so on a Prescribers Order sheet separately

8. BPMH Goal: Complete, accurate list of patient’s HOME medications
Document how the patient is ACTUALLY taking the medication…do not assume
If pt taking it differently than prescribed, note how it was prescribed in the Comments section.
Use generic drug name whenever possible

9. BPMH - Sources
Ideally, validate the history using at least TWO (2) sources of information.
Pt/Family, bubble packaging, med list, Netcare PIN, MAR from another facility, Community Pharmacy printout, etc.
2 sources may not always be available
Netcare Medication Profile/PIN is only ONE of many potential sources and is not always accurate!
Document the sources used on the BPMH sheet (checkboxes)

10. See handout copy

11. Medicated creams/ ointments
Interview Tips: “HEAD TO TOE”
Eye
drops
Ear drops
Medicated creams/ ointments
Inhalers
Injections
Nasal
sprays
Medicated
patches
Prompt questions starting from the head to toe
Are you using any:
Acetylsalicylic acid
Eye drops
Ear drops
Nasal sprays
Inhalers
Injections
Medicated creams or ointments
Medicated Patches
Vitamins, herbals or minerals
Over-the-counter products (OTCs) and;
Have you taken any antibiotics in the last three months?

12. When do I NOT need to complete a BPMH?
Direct admits from another facility
If they already have a completed admission BPMH (copy to be faxed to your site).
The BPMH will not serve as inpatient orders, only as a history/reference
A new BPMH does not need to be completed.
Write admission orders per usual process pre- MedRec implementation (using other facility’s BPMH and transfer orders as reference)
Exception to the rule!!
This is because the BPMH is intended to represent HOME medications.
For example, patient admitted at RAH – admission BPMH completed there. Then the patient was directly sent to GNCH from RAH. At GNCH, a new BPMH is not required to be done; the team is to refer to the RAH BPMH. This is what we would call an external transfer, technically.
This way, when the patient is discharged from GNH, they can refer back to the original BPMH. The patient needs to know what has changed from their HOME medications.

13. How to Complete the BPMH Tool
The admitting prescriber will be completing the BPMH for all non-elective admissions (i.e. ER admits and direct admits. Exception: Vascular Direct admits during clinical pharmacist hours will be completed by Pharmacist, if available)
All elective admissions will have a BPMH previously completed by a Pharmacy Technician in Preadmission Clinic (PAC)
See “How to Fill Out a BPMH Tool” and more on CompassionNet
Care and Safety → Medication Management Initiatives →Medication Reconciliation
The collection of a patient’s medication history is not new.
What is new is the creation of a structured process to ensure the medication history is comprehensive and accurate and that all the discrepancies are addressed.

14. BPMH Documentation:
Even if a medication is an OTC product, it is still written in the top/main section IF it has been PRESCRIBED/recommended by a licensed health care professional.
If it was not prescribed to the patient, document in the Self-Prescribed Section (see next slide)
Information Sources can include: medication vials, bubble packs/dosettes, Alberta Netcare PIN Profile, medication discharge plan, etc.
A list and explanation of the information sources can be found in the HOW TO: Complete Admission BPMH Guide in the Champions Handout.

15. Self-Prescribed Medications Section
Any medication(s) the patient independently decided to take.
If you would like any of these to be continued in hospital, additionally write an order for them on the Patient Care Order (pink) sheets.

16. Reconciling the BPMH
This is the section where the prescriber orders to continue, discontinue, or change the HOME medications, and WHY

17. What do the columns mean?
“Continue”:
The prescriber would like the medication to continue in hospital exactly as written. This serves as a Prescriber’s Order.
“Discontinue”:
The medication will be stopped. Please include REASON.
“Change”:
The medication will still be ordered, but in a different way. (Changed dose, route and/or frequency).
Please include REASON.
Additionally, write the new order on a Patient Care Order (pink) sheet.
This is the RECONCILIATION. Always make a note of any previously written orders if there are any. TIP: instructions are on back of sheet!

18. What if I discover after the BPMH has been reconciled and processed as orders that a HOME medication was missed on the original list?

19. Late Entries/Addendums
New information may be learned about the patient’s HOME medications after the BPMH is processed.
Because this history is referred to at all key transition points, it should be as accurate as possible.
Any licensed health care professional may document an addendum. Write “Late Entry” along with the name, dose, frequency and route of the medication
Date, time and sign your entry
If there is no room, start a new admission BPMH page and renumber all associated pages
Whoever discovers the info should document the late entry (RN, Pharmacist, MD, NP).

20. Late Entries/ Addendums
As usual, Prescriber will be notified to address the discrepancy
NOT to be processed/scanned to pharmacy again
Any orders needed are to be written on the Patient Care Order (Pink) sheets C
SCANNED

21. Where will the BPMH be kept?
The BPMH will be kept in the Patient Care Orders Section (pink sheets) of the chart
It will be the top page of the section and be placed opposite the pink sheets
This is so the BPMH is easily accessible for review when the prescriber writes orders

22. What are my responsibilities?
Admitting prescriber completes:
HOME medications “History” (left) section for all non-elective admissions (ER and direct admits) within 24h of admission*.
*See exceptions on flow map
All elective patients will have a BPMH previously completed in PAC by a Pharmacy Technician
BPMHs will be completed typically in ER. BPMHs will be placed in a clear sleeve in the doctors orders section, along with any other documents used to create it (PIN, med lists etc.)

23. ADMISSION FLOW MAP

24. When to reconcile?
It is at the discretion and clinical judgment of the admitting prescriber whether to complete the Prescriber Reconciliation section at admission (pre-op) or to wait until post-op This will depend on imminence of the surgery, etc. In either case, the BPMH can only be reconciled and used as orders ONCE (pre-op OR post-op, not both).

25. What are my responsibilities?
Write any other medication and non- medication orders, including any changed home medications, on a regular Patient Care Order (pink) sheet.
Document and address late entries (if other staff discover an addendum, they will notify you, per usual practice.)

26. Tip
Any other place the medication history needs to be listed; “See BPMH” may be written or stamped.

27. Transfer

28. Transfer A change in service and/or level of care within the facility
ex. Grey Nuns Surgery to Grey Nuns Internal Medicine 
Attending physician rotation (on same service) is not considered a transfer
Within-service bed changes are not considered transfers
When the doctors on the same service rotate through on a weekly/biweekly basis, this is not a transfer.
Important to stress here the “common lingo” of transfer and how the word is misused.
a change in service, service provider, and/or level of care within the facility (eg. unit-to-unit transfer including from the intensive care unit to medicine unit and/or from vascular surgery to internal medicine)

29. Patient physically leaves the facility
Transfer vs. Discharge MedRec
Transfer
Discharge
Patient remains within the facility
From Unit To Unit
Patient physically leaves the facility
Out of the Hospital Setting (ex. Home, group home, independent living) OR
Out of a facility to another healthcare facility (ex. Grey Nuns Hospital to Youville Home)
CIS calls it a “transfer” from GNH to RAH, but in our terms, and health record’s terms, the correct terminology is DISCHARGE

30. What do I complete on transfer?
A sticker will be used.
Formally documents in a standardized fashion that you have reviewed the BPMH and current medications prior to patient transfer.
Stickers at GNH will be white.

31. What about IMCU Transfer to Ward?
(GNCH Only)
Prescriber will check off this box
on the Preprinted Orders
Page 3 of the PPCO – just before signature.

32. What are my responsibilities?
Review BPMH and current medications prior to patient transfer within-hospital.
Place MedRec Transfer sticker on Patient Care Orders (pink) sheet along with any transfer orders you are writing.
Sign, date and time the sticker.

33. Discharge Or Medication Profile
Healthcare providers compare the most up-to-date medications the patient/resident was receiving on the unit (Medication Administration Record (MAR)) with those that were being taken at home (Best Possible Medication History (BPMH)) to determine the patient/resident’s discharge orders.
This is documented on the Medication Reconciliation Discharge Medication Order and/or Prescription tool

34. Please Note:
********** The MedRec Discharge Tool will be completed for Vascular Surgery discharges ONLY at this time, and only when the Vascular Pharmacist is on duty and able to assist with completion. **********

35. Discharge MedRec Tool Date and Time Community Pharmacy Information
Prescribers Orders
Bubble Packaging
Requested
Discharge Medication
List
Discontinued
Medications (Prescribed
and Self-prescribed)
Prescriber Name and
Signature
Unit Contact Information
Prescription/Quantity
Page #s
Other Important Information
Community Pharmacy
Information

36. Why a Discharge MedRec Tool?
Complete and accurate list of discharge medications
Plus a list of discontinued home medications
Once signed by prescriber:
Discharge medication orders (if patient going to another facility) and/or
Prescription (if a quantity specified)
Replaces current discharge prescription process
Includes OTCs and prescription medications.

37. Discharge Tool
Lists all medications the patient is to take after being discharged from the site.
Beside each medication, it is indicated whether the medication is:
Continue – Unchanged PRE-ADMISSION medication
Changed – PRE-ADMISSION medication has been changed during hospitalization (dose, route, or frequency). Include rationale in space provided.
New – New medication started while in hospital. Include rationale in space provided.
In the “Discontinued HOME Medications” section (see stop sign), any HOME medications that were discontinued during hospitalization and are NOT to be given on discharge, are listed.
Includes OTCs and prescription medicaitons

38. Discharge Tool
When a prescription is required, quantity +/- refills is indicated in the designated columns
If no qty or refills are required, strike a line through the column(s)
Triplicate (TPP) medications should still be listed on the discharge tool to ensure the list is complete
Additionally, a Triplicate Prescription is required (unless the patient is going directly to another inpatient facility)
FYI: Instructions are also on the back of the white copy (top copy) of the form
Includes OTCs and prescription medicaitons

39. Discharge Tool: Two-ply
White ply:
Chart/Prescription copy. Can be faxed to community pharmacy, etc.
Yellow ply:
Copy for patient/caregiver for their records
White ply:
Chart copy. If ordered, can be faxed to appropriate receiving community pharmacy and/or facility, as well as to the patient’s family physician. If patient would prefer to take this copy in person to his or her pharmacy, a copy of it must be made to keep in the chart.
Yellow ply:
Pre-marked as “not a prescription”. Copy for patient/resident or caregiver for information purposes (to be provided along with patient ply of the Short Stay Discharge Summary Form). Patient/caregiver will always receive this copy of the tool.

40. Discharge directly to another facility
Discharge tool serves as discharge medication orders that can be faxed to the next facility.
All other non-medication related discharge orders should be written as per usual on the Patient Care Order (pink) sheets.
The admission BPMH should be faxed to the receiving facility along with the Discharge Tool.
Check off “Send Admission BPMH”
This provides the receiving facility with an understanding of the patient’s home medications as well.
If the patient is being sent directly to another healthcare facility, it is important that in addition to sending the Discharge MedRec tool, the admission BPMH is faxed to them as well.

41. DISCHARGE FLOW MAP

42. What are my responsibilities?
Discharging Vascular Prescriber to liaise with Vascular Pharmacist who will assist with completion of the tool when available on duty.
(Usual hours M-F 0800h-1530h)
Sign/date/time the MedRec Discharge Tool (Prescriber must complete final review/signature).
If Clinical Pharmacist is unavailable, Discharge MedRec will not be mandated.

43. Tip
Any other place the discharge medications need to be listed, “See MedRec” may be written or stamped.

44. MedRec Resources MedRec Flow Sheet/Responsibilities Poster
CompassionNet
Internal (How To) and External Resources
MedRec Policy VII-B-235
On Deck with MedRec Newsletters
MedRec Info Binders
Binder will be at unit clerk’s desk
MedRec Flow Sheet/Responsibilities Poster
Will be posted on your unit
MedRec Project Team
Will show on next slide how to get to the MedRec CompassionNet landing page.

45. MedRec Page: CompassionNet
1. Go to
Tip: Add to bookmarks, or a shortcut on desktop 
2. Click “Care & Safety”
3. Then click on
4. Then click on

46. When does implementation begin?
Monday June 15, 2015
Until then, follow current unit practices already in place.

47. Local Implementation Begin with “Kick-Off Event” – see posters
Week One: Project Team is physically present on site for first week and via pagers
Support the MedRec Champions
Coaching & guidance for local staff on the use of MedRec tools/processes
Week Two: Project Team available remotely via pagers
Two weeks in: auditing commences
End with “Celebration Event” – see posters
Kick off June 15th, Celebration June 25th.

48. Questions/Feedback? Local Unit MedRec Champions MedRec Team
During implementation dates: in-person and via pagers;
(pager hours will be posted on the units)
Pager #1: (780)
Pager #2: (780)
Any time at:
Pager numbers will be posted on your unit at main desk. To reach us instantly for those issues/questions that arise in the moment – page if you don’t see one of us!