Medication Reconciliation: Obtaining a Best Possible Medication History

1. Medication Reconciliation: Obtaining a Best Possible Medication History

2. Objectives By the end of this session, staff will be able to: • Recognize the potential for dangerous medication errors in all clinical encounters • Define medication reconciliation • List the steps needed to develop an accurate medication list • Understand how to obtain a Best Possible Medication History (BPMH)

3. “Medication” Any prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, vaccines, or over-the-counter drugs; diagnostic and contrast agents; radioactive medications; respiratory therapy treatments; parenteral nutrition, blood derivatives, and intravenous solutions; and any product designated by the Food and Drug Administration (FDA) as a drug. Image retrieved on 25 Feb 2014 from: http://www.flickr.com/photos/63976515@N05/6556949031 Creative Commons License Associated: creativecommons.org/licenses/by/2.0/

4. Studies have shown that the biggest cause of potentially harmful errors in the medication reconciliation process is errors in taking the preadmission medication history. Taking an accurate history is a challenge for many reasons: • Patients/caregivers often have a poor understanding of their medication regimens • Patients may be unable to communicate at the time of hospital admission • Patients do not bring their pill bottles to the hospital nor have an accurate and up-to-date list • Patients have many providers, and no one provider takes ownership for ensuring the accuracy of the medication list • We have a fragmented medical system with many different medical record systems that don’t talk to each other • There is no single “source of truth” for medication information (or any medical information)

5. Medication errors at Vanderbilt: In recent studies: • 50% of patients experienced a clinically important medication error after discharge1 • 42% of patients had at least 1 error in pre-admission med list2 • More common with a higher number of pre-admission medications • Less common when a recent medication list (<90 days) was present • 39% of patients had at least 1 error in discharge medication list2 • Clinically relevant discharge medication errors were associated with impaired cognitive function, higher number of pre-admission list errors, and more medication changes during hospitalization 1. Kripalani et al. Ann Intern Med 2012. 2. Salanitro et al. J Gen Intern Med 2012.

6. Implications of medication errors • Potential for patient harm • Actual patient harm • Adverse drug events • ED visits • Hospital admissions and readmissions • Prolonged length of stay • DEATH • Patient and provider dissatisfaction

7. How do we address this problem? • What can we do to prevent/minimize the occurrence of these medication errors?

8. Medication Reconciliation Goal= To provide the correct medication to the patient at all transition points within the healthcare system Complete and Accurate Medication List It is everyone’s responsibility!

9. VERIFICATION: obtain and document a complete and accurate list of the patient’s medications, including name, dosage, frequency, route, last dose, indication Med Rec: The Process VALIDATION: review current medications and indicate which are to be continued, changed, temporarily held, or discontinued CLARIFICATION: compare that list with new medications being ordered for the patient, in order to identify and resolve discrepancies COMMUNICATION: relay the complete list of medications to other providers and to the patient when he or she leaves the organization’s care

10. It all starts with the medication history… Garbage In = Garbage Out Get it right from the start! If you take an accurate and complete medication history on the front end, it will save you time and you are less likely to harm your patients inadvertently in the end.

11. What is the role of the Nurse? • To collect the Best Possible Medication History upon admission • To advocate that the patient’s home meds be considered as the patient’s condition changes during the admission (i.e., restarting of psychiatric medications or hormonal therapy) • To educate patients on discharge medications using the patient letter following provider completed Medication Reconciliation. This step facilitates correct timing and dosing of medication upon returning home.

12. Best Possible Medication History • A medication history that includes: • A systematic process of interviewing the patient/caregiver • A review of at least one other reliable source of information to obtain and verify all of a patient's medication use (prescribed and non-prescribed) • Drug name, dosage, route and frequency

13. Tips for obtaining a medication history • Do your pre-work • Review available materials before talking to patient • Past Medical History, patient summary if VUMC clinic patient • Records sent or scanned in from outside facility • Be systematic • Use the same approachevery time • Start by having the patient tell you what he is taking • To clarify medications and ensure a complete list, ask probing questions (next slides) • Use at least 2sources • Patient, caretaker, computer list, patient’s list, pill bottles, pharmacy, etc. • Medication information should include • Name (generic and brand) • Formulation (ie. patch, cream, extended release tab) • Dose • Route • Frequency • Indication • Pertinent comments • Start date, last dose taken, adherence • Include both prescription and non-prescription medications • Don’t assume the patient is taking his medications as prescribed

14. Example questions • Do your pre-work • Has the patient been seen at Vanderbilt before? • Is there any documentation in StarPanel to review? • Check the date of the last documented list. A list that is 2 years old is likely not a reliable source! • Be systematic • Start by having the patient tell you what he is taking • “I have some information about medications you take at home, could you tell me what you are currently taking and we can check that the list is correct?” • “What medications do you take at home?” • Use at least 2sources • “Do you happen to have your own medication list or any pill bottles with you?” • “Is your spouse/parent/other able to help list your home medications?” • “Where do you get your medications filled?”

15. Probing Questions • By patient’s condition or disease • What medicines do you take for your diabetes, high blood pressure etc? • Medications that are easy to forget • “Do you take any medicines once a week or once a month?” • “Do you take any inhalers, nasal sprays, patches, eye drops, creams/lotions or injections?” • PRN medications • “Are there medications you take only sometimes?” (like when you have a headache, allergy symptoms, constipation, heartburn, to help you fall asleep) • Non-prescription products • “Do you take vitamins, herbs, or products purchased off the shelf that don’t require a prescription?” • Don’t assume the patient is taking his medications as prescribed • “When did you take the last dose of each medicine?” • “In the last week how many days have you missed a dose?”

16. Next Steps • Now that you now how to collect the best possible medication history, review the accompanying educational module. It will review how to use the Medication List Tool (MLT) to record the collected medication information to the Electronic Medical Record