1. Pharmacy Services Medication Reconciliation Using PharmaNet-based Forms … It’s about the conversation. 2010

2. Pharmacy Services Outline Why reconcile? What is Medication Reconciliation? Change of Practice PharmaNet-based Med Rec Forms Obtaining a Best Possible Medication History (BPMH) Documenting the BPMH on the PharmaNet-based Med Rec Form Processing Medication Reconciliation Orders

3. Pharmacy Services Why Reconcile? Over half of medication errors occur at the interfaces of care Rozich JD, Reser RK. Medication Safety: One Organization’s Approach to the Challenge. J Clin Outcomes Manage. 2001;8(10): 27-34 An up-to-date and accurate medication list is essential to ensure safe prescribing in any setting Safer Healthcare Now! Getting Started Kit: Medication Reconciliation Prevention of Adverse Drug Events

4. Pharmacy Services Medication Reconciliation Working Definition: …a formal, systematic process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at transitions of care.

5. Pharmacy Services Medication Reconciliation Working Definition: …a formal, systematic process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at transitions of care.

6. Pharmacy Services Medication Reconciliation Prevent Unintentional Discrepancies Document Intentional Discrepancies

7. Pharmacy Services Medication Reconciliation

8. Pharmacy Services Medication Reconciliation Three step process: –Collection –Clarification –Reconciliation  Medication Orders Best Possible Medication History (BPMH)

9. Pharmacy Services Change of Practice (Admission) Current state Multiple individuals take medication histories and document them in different locations in the clinical record Medication orders are written on a separate form Discrepancies occur without any effective way of identifying or resolving them Future state One individual will obtain and document the best possible medication history (BPMH) The prescriber will confirm/write medication orders on the same form to increase transparency and eliminate transcription errors

10. Pharmacy Services Standard Forms Use data in existing databases to: –Minimize transcription –Ensure no active orders are overlooked Formatted to support three-step process: –Collection (existing data) –Clarification (modified/additional data) –Reconciliation  medication orders Transparent process –Apparent to all subsequent caregivers Documentation of BPMH in single location at admission which can be referred to at discharge

11. Pharmacy Services Medication Reconciliation at Admission Three step process: –Collection –Clarification –Reconciliation

12. COLLECTION CLARIFICATIONRECONCILIATION

13. COLLECTION CLARIFICATION RECONCILIATION

14. Pharmacy Services Best Possible Medication History An up-to-date and accurate medication list is essential to ensure safe prescribing in any setting Safer Healthcare Now! Getting Started Kit: Medication Reconciliation Prevention of Adverse Drug Events Goal is to determine how a patients is actually using their medications (versus how they were prescribed) Three steps: –Preparation –Conversation –Documentation Tools available at: http://vchconnect/programs_services/regional_pharmacy/ medication_reconciliation/resources/page_69550.htm http://vchconnect/programs_services/regional_pharmacy/ medication_reconciliation/resources/page_69550.htm

17. Pharmacy Services Preparation Review chart for clinical conditions and any medication lists obtained previously Print and review the patient’s PharmaNet-based Medication Reconciliation Form from CareConnect

18. Pharmacy Services Limitations of PharmaNet Record of prescriptions dispensed Reflect current use of prescription medications less than 30% of the time Shalansky, S et al: Accuracy of a Prescription Claims Database for Medication Reconciliation for Outpatients with Heart Failure. Can J Hosp Pharm 2007;60(3):169-176 Information in PharmaNet MUST be clarified/verified with the patient or caregiver

19. Pharmacy Services Limitations of PharmaNet MAY contain discontinued medications Does NOT contain –Updated administration instructions –Non-prescription drugs –Samples –Investigational/clinical trial drugs –Complementary and alternative therapies –Antiretrovirals, some chemotherapeutic agents and vaccines –Prescriptions obtained outside of BC or over the internet Fraudulent use Information in PharmaNet MUST be clarified/ verified with the patient or caregiver

20. Pharmacy Services Printing PharmaNet-based Forms Forms are accessed via CareConnect Detailed instructions are available at: http://vchconnect/programs_services/regional_pharmacy/medication_ reconciliation/page_67071.htm http://vchconnect/programs_services/regional_pharmacy/medication_ reconciliation/page_67071.htm

21. Patient Identification Total Pages and Print Date

22. Pharmacy Services Interpreting PharmaNet Entries Generic name, strength and dosage form of medication Usage instructions Fill date Prescriber Prescription status Fill quantity

23. Pharmacy Services Preparation continued Review chart for clinical conditions and any medication lists obtained previously Print and review the patient’s PharmaNet-based Medication Reconciliation Form from CareConnect Anticipate non-prescription medications based on clinical history + PharmaNet Review any medication containers that the patient brought to hospital Arrange for a translator or family member to assist if required

24. Pharmacy Services Conversation

25. Pharmacy Services Conversation Introduction Ask to see home medications if available Ask patient to describe why and how they are taking each medication regardless of what is on the label or in PharmaNet Ask specifically about: –nonprescription medications, especially aspirin analgesics (acetaminophen, ibuprofen) vitamins, calcium, iron and other supplements allergy medications, eye drops, creams, etc –Samples –Previous adverse effects (or lack of effect) of medications Any further questions?

26. Pharmacy Services Conversation

27. Pharmacy Services Documentation

28. Pharmacy Services Documentation

29. Pharmacy Services Documentation – Peri-op

30. Pharmacy Services Reconciliation

31. Pharmacy Services Summary Why reconcile? What is Medication Reconciliation? Change of Practice PharmaNet-based Med Rec Forms Obtaining a Best Possible Medication History (BPMH) Documenting the BPMH on the PharmaNet-based Med Rec Form Processing Medication Reconciliation Orders

32. Pharmacy Services Acknowledgements Crystal Amos, Medication Safety Pharmacist, Vancouver Acute HSDA Jane de Lemos, Coordinator, Professional Practice, VCH-PHC Pharmacy Services Debbie Jeske, Interim Director, Peri-operative Services, Vancouver Acute HSDA Elinor Orsini, Patient Services Coordinator, Preadmission Clinic, Vancouver Acute HSDA Fruzsina Pataky, Medication Safety Coordinator, VCH-PHC Pharmacy Services