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Medication Reconciliation Johns Hopkins Hospital March 2006 Bob Feroli, PharmD, FASHP.

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Presentation on theme: "Medication Reconciliation Johns Hopkins Hospital March 2006 Bob Feroli, PharmD, FASHP."— Presentation transcript:

1 Medication Reconciliation Johns Hopkins Hospital March 2006 Bob Feroli, PharmD, FASHP

2 Transition of Care Patient’s previous home medications are not considered when writing discharge orders. Patient is discharged on Zocor (simvastatin). Patient’s previous home medications are not considered when writing discharge orders. Patient is discharged on Zocor ® (simvastatin). At home, patient starts Zocor and continues to use previously prescribed Lipitor (atorvastatin). At home, patient starts Zocor ® and continues to use previously prescribed Lipitor ® (atorvastatin). Eleven days later, patient is admitted with severe rhabdomyolysis secondary to “statin” overdose.

3 Transition of Care Patient with Parkinson's disease is admitted to an ICU for an acute episode unrelated to Parkinson’s disease. Initial care is focused on the acute episode and anti- Parkinson’s drugs are not used. Patient is transferred to general care unit, “Home” therapy is not considered and anti-Parkinson’s therapy is not started. Patient develops severe Parkinsonian symptoms.

4 Transition of Care Discharge orders for 33 randomly selected ICU patients were reviewed by an RN in context with the patient’s home medications and ICU meds. Potential discrepancies were brought to the attending of the ordering physician. Discharge orders for 31 of 33 patients (94%) were changed. Pronovost P, et al. J Crit Care 18(4):201-205, 2003

5 Transition of Care Errors can occur when a patient’s care is passed from one group to the next Errors can occur when a patient’s care is passed from one group to the next Medication therapy may be inappropriately: Medication therapy may be inappropriately: Continued Continued Omitted Omitted Changed Changed Duplicated Duplicated

6 Medication Reconciliation Reassessment of medication therapy as a patient moves from one level of care to the next. When properly done will: Reassessment of medication therapy as a patient moves from one level of care to the next. When properly done will: Support continuity of care Support continuity of care Help to avoid medication errors Help to avoid medication errors JHH quality improvement priority for FY06 JHH quality improvement priority for FY06 Documentation is mandated by JCAHO Documentation is mandated by JCAHO Effective Jan 1, 2006 Effective Jan 1, 2006

7 AdmissionTransfer Discharge

8 AdmissionTransfer Discharge

9 AdmissionTransfer Discharge Eclipsys SCC?

10 AdmissionTransfer Discharge Eclipsys SCC? ICUs IMCs Adult Onc Nel-7

11 AdmissionTransfer Discharge Eclipsys SCC? YES

12 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Eclipsys SCC? YES

13 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Eclipsys SCC? YES Home Meds Rx medications Sample medications Herbal remedies VitaminsNutriceuticals OTC drugs

14 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Eclipsys SCC? YES

15 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Clerical Assoc. or RN Prints Home Medication Reconciliation form Eclipsys SCC? YES

16 AdmissionTransfer Discharge Enter “home” medications into Eclipsys Print Home Medication Reconciliation form Eclipsys? YES

17 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Clerical Assoc. or RN Prints Home Medication Reconciliation form Eclipsys SCC? YES

18 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Clerical Assoc. or RN Prints Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? YES No

19 AdmissionTransfer Discharge Enter “home” medications into Eclipsys Print Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? No

20 AdmissionTransfer Discharge Enter “home” medications into Eclipsys Print Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? No Initial Med List Entered by: Patient Pt family member Nurse Physician Pharmacist other

21 AdmissionTransfer Discharge Enter “home” medications into Eclipsys Print Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? No Provides one location for the home med list Initial Screening Form H&P “See home med reconciliation form”

22 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Clerical Assoc. or RN Prints Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? YES No

23 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Prescriber considers home med list when developing admission orders Clerical Assoc. or RN Prints Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? YES No

24 AdmissionTransfer Discharge RN enters “home” medications into Eclipsys Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Clerical Assoc. or RN Prints Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? YES No

25 AdmissionTransfer Discharge Enter “home” medications into Eclipsys Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Print Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? YES No

26 AdmissionTransfer Discharge Enter “home” medications into Eclipsys Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Print Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? YES No Place form into chart behind Med Administration tab

27 AdmissionTransfer Discharge Enter “home” medications into Eclipsys Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Print Home Medication Reconciliation form Fill out Home Medication Reconciliation form Eclipsys SCC? YES No Place form into chart behind Med Administration tab

28 AdmissionTransfer Discharge

29 AdmissionTransfer Discharge

30 AdmissionTransfer Discharge Sending Unit POE and/or Eclipsys Receiving Unit

31 AdmissionTransfer Discharge Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit

32 AdmissionTransfer Discharge Sending Unit POE and/or Eclipsys Receiving Unit Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form

33 AdmissionTransfer Discharge Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit

34 AdmissionTransfer Discharge Non-Eclipsys and Non-POE Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit

35 AdmissionTransfer Discharge Non-Eclipsys and Non-POE Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

36 AdmissionTransfer Discharge No-Eclipsys and No-POE Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form

37 AdmissionTransfer Discharge No-Eclipsys and No-POE Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

38 AdmissionTransfer Discharge Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

39 AdmissionTransfer Discharge Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

40 AdmissionTransfer Discharge Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit

41 AdmissionTransfer Discharge Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit

42 AdmissionTransfer Discharge Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

43 AdmissionTransfer Discharge Place form into chart behind Med Administration tab Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

44 AdmissionTransfer Discharge Place form into chart behind Med Administration tab Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

45 AdmissionTransfer Discharge Place form into chart behind Med Administration tab Prescriber considers “Home” Med List and Meds used just prior to discharge When developing discharge orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

46 AdmissionTransfer Discharge Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit

47 AdmissionTransfer Discharge Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Receiving Unit

48 AdmissionTransfer Discharge Place form into chart behind Med Administration tab Prescriber considers “Home” Med List and Meds used just prior to discharge When developing discharge orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse patient specific sends patient specific Transfer Reconciliation form Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse non-patient specific sends non-patient specific Transfer Reconciliation form Receiving Unit

49 Medication Reconciliation Next Steps Improve compliance with current system Improve compliance with current system Automate reconciliation process Automate reconciliation process Improve reconciliation in outpatient sector Improve reconciliation in outpatient sector

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