Medication Reconciliation

1. Medication Reconciliation Veterans Affairs North Texas Health Care System March 2008

2. Objectives • Explain the purpose of medication reconciliation • Identify what medications and/or products need to be included in medication reconciliation process • Describe when medication reconciliation occurs in the inpatient and outpatient setting

3. Joint Commission Patient Safety Goal #8 • National Patient Safety Goal 2008 • Accurately and completely reconcile medications across the continuum of care http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_npsg_facts.htm

4. Definitions • Medication Reconciliation • A process of identifying a patient’s current list of medications that involves the patient and/or family as appropriate • Medications • Prescription medications (VAandnon-VA) • OTC medications • Herbals, neutraceuticals, supplements, vitamins

5. Definitions • Patient’s Home Medication List • All current medications including VA, Non-VA, over-the-counter (OTC) products and herbal supplements • “Referred” Provider • A provider within or outside the VA system in which a patient is referred to

6. Intent of This Safety Goal • Avoid medication errors • Omissions, duplications, dosing errors, drug interactions • Determine appropriate therapy • Providers will decide and order medications that need to be continued, discontinued and/or require a dose change

7. Intent of This Safety Goal • Ensure that a complete medications list is communicated to the next provider when the patient is transferred to: • Another setting, service, practitioner or level of care • Regardless if it is within the North Texas VA system or outside the organization

8. Responsibility • The ordering provider, physician assistance, nurse practitioner, nurse, case manager and pharmacist will work together to ensure the completion of this process

9. Responsibility • The ordering provider is responsible for ensuring the completion of this process • Another caregiver (nurse, clinical pharmacist) may complete this process; however, their reconciliation must be communicated to the patient’s provider

10. Inpatient

11. Admission • Patient’s “home medication list” must be documented in the admission (H&P) note • MUST include: outpatient medications (VA and non-VA), vitamins, OTC and neutraceuticals • Document non-VA medications, OTC products and herbal supplements in • “Orders” tab  “Medication, Non-VA” section

12. Change in Level of Care • Applies to change in level of care, provider or setting • Compare (or reconcile) current medications with new medication plan • Address errors (omissions, duplications, drug-drug interactions) • Complete and Sign new med orders

13. Documentation: Changes • Once new medication orders have been signed, document a statement certifying reconciliation of all active meds in patient care note or generate a “Medication Reconciliation Note” in CPRS

14. Documentation • A CPRS Medication Reconciliation Note may be produced by going to: • “Notes” tab click “New Note” • Type Medication reconciliation as note title • This note will auto populate with new medication list **MUST enter new medication orders prior to creating note**

15. Template

16. Documentation • Patient Transfer Notes must include a complete listing of the patient’s active medications

17. Documentation • If unfamiliar with a medication found in patient’s medication orders two options • Take no action • Consult with original prescriber or a pharmacist • If another caregiver (i.e. nurse, pharmacist) generates the reconciliation note • This action must be communicated to the patient’s provider

18. Discharge • Provider will compare (reconcile) the patient’s inpatient medications with “home medication list” • Order and sign discharge medications • Nurse may print the “Inpatient Discharge Instructions” for the patient • Will reflect current outpatient and Non-VA medications only

19. Discharge • If patient is referred to a provider outside VA system: • It is VA staff’s responsibility to communicate the medication list to the “referred” provider • It is NOT the patient’s responsibility

20. Outpatient

21. Initial and Follow-up Visits • “Patient’s Home Medication List” • Current outpatient and non-VA medications • Prescription, OTC, vitamins, neutraceuticals • Documented as the “meds” tab

22. Initial and Follow-up Visits • Plan is known for outpatient medication • “Orders” tab • Add new medications • Document non-VA meds • Under “Medication, Non-VA” section • Discontinue medication therapies if warranted • Renew all medications that may expire prior to next visit (remove any duplicate orders) • Sign medication orders

23. Documentation: Changes • “Notes” tab click “New Note” • Type Medication reconciliation as note title • The note will auto populate with medications **MUST enter new orders prior to creating note** • New orders will show as pending • EXCEPTION: Schedule 2 Controlled medications must be documented under the templates “Comments section”

24. Documentation: Changes • PRINT to dedicated medication reconciliation printer • Instruct patient to pick-up medication list from MAS clerk (or designee) as they leave the clinic • Instruct patient to bring list to ALL clinic visits regardless of provider • If multiple clinic visits • Generate note as described previously • Last clinic provider will print the final medication list

25. Documentation: No changes • If NO new medications are ordered, changed or discontinued • Add addendum to patient care note documenting the appropriateness of the current medication plan

26. Documentation • If unfamiliar with a medication found in patient’s medication orders two options • Take no action • Consult with original prescriber or a pharmacist • If another caregiver (i.e. nurse, pharmacist) generates the reconciliation note • Reconciliation must be communicated to the patient’s provider

27. Referred Provider • If patient is referred to a provider outside VA system: • It is VA staff’s responsibility to communicate the medication list to the “referred” provider • It is NOT the patient’s responsibility

28. Assessment Questions • In the inpatient setting, medication reconciliation occurs upon: • Admission • Change in level of care • Change in setting • Change in provider • All of the above Very IMPORTANT that patient’s medications are reconciled to ensure patient safety throughout the continuum of care

29. Assessment Questions • In the outpatient setting, “medication reconciliation” notes are created when NO changes to medications are made • True • False The note is created ONLY if changes (starting, stopping or changing medications) occur

30. Assessment Questions • “Discharge” instructions (inpatient) or “Medication Reconciliation” note (outpatient) MUST be printed and given to the patient • True • False Discharge instructions or medication reconciliation note MUST be printed and given to each patient in order for them to bring to follow-up visits with other providers

31. Assessment Questions • Changes, discontinuation or new medication orders need to be placed prior to generating a medication reconciliation note • True • False The template for the “medication reconciliation note” will auto populate with all active or new orders. If the note is generated prior to new orders being entered, the medication list will be WRONG

32. Summary • This is a MANDATORY requirement per Joint Commission Patient Safety Goal #8 • For more information or questions • See VANTHCS Memo P&T 21 • Contact: Joann C. Fenicchia Adm Officer, Clinical Quality Mgmt Telephone Number: (214) 857-2129 Joann.Fenicchia@va.gov • Joint Commission Website • http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_npsg_facts.htm