Medication Reconciliation Journey

1. Medication ReconciliationJourney Terry Haslinger, Munson Medical Center

2. Future Present Past

3. Past • IHI – Impact Patient Safety October 2003 • Trials with Manual Form • Cardiac Cath Patients • Orthopedic Surgical Patients • Urology Patients • Live December 6, 2005 - Cerner

4. Issues we addressed prior to implementation. • Define medication reconciliation • Inpatient • Outpatient • What it includes • Over the counter • Herbals • How medication would be entered • Date and time of last dose • Patient arrives with written order

5. Issues we addressed prior to implementation.(continued) • Patient not taking any drugs • Patient unable to give medication history • Little blue pill • Define the level of care for transfer • Patients going to OR • Down procedure

6. Definition Medication Reconciliation is a process of obtaining a list of the patient’s current medications, including the name of the drug, dosage, route, frequency and time of last dose. Medications must be reconciled upon admission, transfer within the hospital to another level of care, going to surgery, and at discharge.

7. Medication Reconciliation • Over-the-counter medications • Herbals • Patches • Inhalers • Ear/eye/nose drops • Dietary supplements A medication and allergy history is obtained by an RN/LPN from the patient and/or family members who are present at the time the patient presents for care, or at the time of admission. The medication history should include a complete list of prescription and non-prescription medications:

8. Medication Reconciliation (cont.) • The patient’s current pharmacy • The patient’s physician’s office or clinic • The patient’s long-term care facility or home care records • Transfer forms from another facility • Recent hospital discharge forms The RN/LPN should determine if the medication history is being obtained from a reliable source. The source of the medication history must be recorded in the patient’s medical record. It will be entered under “AP information collected from:” on the History/Meds page of the Admission Profile.

9. It Happens Here • Failure to reconcile meds at Admission • 69 yo WM with squamous cell lung cancer • Admitted for dehydration, hypercalcemia, and chemotherapy

10. Medication Reconciliation (cont.) • Enter meds according to patient’s drug and dose taken at home: • Lasix 40mg, two tablets, once per day instead of Lasix 80mg po daily. • Use the ‘comment’ field to type in the date and time of the last dose.

11. Medication Reconciliation (cont.) The next step is to print the medication reconciliation order form for the physician/NP/PA to use to reconcile the patient’s meds. If the patient is going from the Emergency Department (E.D.) to O.R., Cath Lab, etc., in an emergent fashion and there was no time to obtain a medication history, the unit receiving the patient will be responsible for printing the “Admission Medication Reconciliation” order form.

12. Patient Arriving with Written Orders If a home medication is not continued, changed, or discontinued on admission, the nurse must call and reconcile the medication with the admitting physician within 4 hours of admission. Nursing Responsibilities If a patient arrives with orders already written, the admitting RN will review the admission orders to ensure that all home medications have been continued. The Admission Medication Reconciliation order form will be placed on the patient’s chart.

13. Patient Not Taking Any Medications This is entered into the Medication Profile, and an Admission Medication Reconciliation order form is printed and placed in the order section of the gray chart.

14. Unable to Obtain Medication History If the admitting nurse is unable to obtain a home medication history at the time of admission, it should be entered into the Medication Profile.

15. Unable to Obtain Medication History (cont.) Once the correct medication history is obtained, the nurse must update the Medication Profile, as this information is used throughout the patient’s stay and at discharge. Example: Pt. takes a “little blue pill for blood pressure every 6 hours”. When a family member arrived, it was discovered that the little blue pill is Inderal 20mg. The nurse modified the computer entry to the following:

16. Transfer Medication Reconciliation • Intensive and Critical Care • (ICU/P2, CCU, NICU, CTU) • Acute Care • (E2, E4, E4N, SW2, S4, W4, W3, CTSU, CPCU, CIU) All medications that are currently prescribed will be reviewed and reconciled when a patient is transferred between levels of nursing care or post-operatively. Different levels of nursing care are defined as:

17. Transfer Medication Reconciliation (cont.) • Print and place the “Transfer Medication Reconciliation” order form in the patient’s chart. • To ensure that recently changed orders are processed correctly, the nurse on the sending unit will review the Transfer Medication Reconciliation order form for accuracy.

18. Transfer Medication Reconciliation (cont.) • The physician/NP/PA will review the order form and continue or discontinue the medications. The physician/NP/PA will date, time, and sign the form. • Before the form is faxed to Pharmacy for order entry, the person faxing it will date, time and sign the form. NOTE: This process will not be done during/after a code or an emergency situation.

19. Operating Room Medication Reconciliation **In the rareinstance the patient is going to O.R. in an emergent fashion, O.R. will be responsible for printing the Transfer Medication Reconciliation order form. • As part of the pre-op preparation, a Transfer Medication Reconciliation order form will be generated by the UC/RN/LPN and placed on the patient’s chart in the order section.

20. Discharge Medication Reconciliation The patient’s physician/NP/PA will communicate that (s)he intends to discharge the patient from the hospital. A “Discharge Medication Reconciliation” form will be generated by the RN, LPN, UC, Physician, NP, or PA. The Discharge Medication Reconciliation form has ONLY home medications listed.

21. Discharge Medication Reconciliation (cont.) • The patient’s home medications will be continued, discontinued, or changed as noted on the form. New medications ordered for the patient at the time of discharge will be added to the form. • If a med is changed, it should be discontinued and the order rewritten. • 2. For any new medications, the patient will receive a med info sheet. • 3. A copy of the Discharge Medication Reconciliation form should be placed in the order section of the chart. The original will be sent home with the patient.

22. Present

23. Interdisciplinary Task Force • Data collection • Tweak the System • Physician Issues

24. Future • Outpatient Population • Brochure – “Know Your Medication” • South Carolina Hospital Association scha.org • Medication Cards • Community Education/Awareness

25. Barriers • Patient Knowledge About Medications • Electronic Medical Record

26. Keys to Success • Downtime Plan • Identify the Champions • Role of Administration • Medical Staff – Value Added

27. Key to Success cont. • Communication Plan – Ongoing • Education Plan – Ongoing • Flow Chart the Process • “It Happens Here” Testimonials