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Medication Reconciliation: Discharge Timeout
Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents
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Overview Medication reconciliation is a vital part of patient care and safety Maintains continuity of care Ensures appropriate continuation/discontinuation of medications at admission and discharge Discharge timeout process Accountability Continuity Safety
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What is Med Rec? Medication reconciliation is a process to determine what Rxs, OTCs, herbals/supplements a patient is currently on Why do we need to do this? Continue regimen while in the hospital Determine if any medications are contributing to the patient’s condition Possibly increase/decrease or discontinue meds
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How is Med Rec Used? Physicians review med rec prior to entering admission orders If med rec is entered incorrectly, inpatient medications can be continued incorrectly and may lead to patient harm Inpatient and discharge medications are also chosen from the med rec
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Importance An accurate med rec allows for a safe transition of care both into the hospital and discharge to home When we know exactly what the patient taking at home, it allows for the highest level of medication optimization
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Medication Reconciliation
Performed by Pharmacist Pharmacist Interns Multi-step process Review home medication list & External med history Perform patient interview Submit correct med rec into EMR Compare home meds with inpatient meds Contact ordering physician or practitioner
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Medication Reconciliation
IMAGE OF BAD MED REC
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Discount Double Check
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Discharge Timeout= Discharge Double Check
Estimate of 2 in 5 patients in the hospital has discrepancies in their medication reconciliation that a pharmacist can correct and intervene1 56% reduction in chart discrepancies at discharge2 Multi-step Nurse-nurse, nurse-pharmacist check Admission Discharge Bishop MA, Cohen BA, Billings LK, Thomas EV. Reducing errors through discharge medication reconciliation by pharmacy services. Am J Health Syst Pharm. 2015;72(17 Suppl 2):S120-6. Ruggiero J, Smith J, Copeland J, Boxer B. Discharge Time Out: An Innovative Nurse-Driven Protocol for Medication Reconciliation. Medsurg Nurs. 2015;24(3):
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Discharge Timeout Form
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Conclusions Med rec is vital in maintaining continuity of care and patient safety Discharge time out process aims to reduce the number of chart discrepancies and negative medication-related patient outcomes South County Hospital Discharge Timeout update
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