Medication Reconciliation
Physicians Learning Package
Created by:
Linda Cawthorn RN, MN
Kim Spiers, BScPharm
Shelly Proft, BScPharm
Objectives:
· Define Medication Reconciliation
· Identify Key Benefits
· Complete a thorough medication history
· Document medication history on the ‘Medication Reconciliation and Physician’s Orders’ form
· Identify roles and responsibilities
· Review Discharge Medication Reconciliation
What is Medication Reconciliation?
· Medication Reconciliation is a patient safety initiative designed to prevent medication errors at transitions in care. It is a process which requires collaboration across multiple professional groups and includes:
o Obtaining a complete and accurate list of each patient’s current home medications (medication, dosage, route and frequency).
o Using the information obtained for physicians to write the home medication admission orders.
o Documenting reasons why home medications are changed or discontinued.
o Bringing discrepancies to the attention of the prescriber and ensuring changes are made to the orders, when appropriate.
o Referring back to the information obtained to write transfer and discharge orders.
Who Requires Medication Reconciliation?
· Medication Reconciliation is required on all patients who receive a medication, treatment or procedure in a health care setting.
Accreditation Standard
· Medication Reconciliation is a required organizational practice to meet a new accreditation standard. Reconciliation must occur on admission, transfer and discharge.
Key Benefits
The goal of medication reconciliation is to prevent adverse drug events through:
· Documentation of the Best Possible Medication History (BPMH) and reconciliation on one form.
· Enhancing communication between all care providers across all settings.
· Matching in-hospital dose, frequency and route with at-home dose or facilitate proper documentation if change is required.
· Preventing inadvertent omission of home medications.
· Preventing failure to restart home medications following transfer and discharge.
Documented Impact
· Implementation of medication reconciliation along with other interventions decreased the rate of medication errors by 70% and adverse drug events by 15%, over a seven month period.[i]
· Implementation in a surgical population reduced potential adverse drug events by 80% within three months of implementation.[ii]
· There was a five fold reduction (1.75% to 0.35%) in the number of medication errors upon admission with implementation of medication reconciliation upon admission.[iii]
· For those with no missing medications, drug related problems after discharge were reduced from 85% with original prescription process, to 35%.[iv]
[i] Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care 2004;13(1):53-59
[ii] Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm 2003;60:1982-1986
[iii] Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. J Qual Patient Saf 2005;31(7):406-413
[iv] Poole DL, Chainakul MP, Graham L. Medication reconciliation: A hospital necessity in promoting a safe hospital discharge. J Healthc Qual (NAHQ) 2006 May/June
How to Obtain the Best Possible
Medication History (BPMH)
· A comprehensive medication history requires a patient interview. If the patient is unable to participate in an interview, involve a family member or other care provider if possible.
· Ask for a home medication list or medication vials from patient.
· Note dates on lists, medication vials, and dosette or blister pack labels to determine if the information is current.
· If the patient provides a dosette or blister pack, ask if they take any medications that are not in the dosette or blister pack. Medications such as Coumadin®, PRN sleeping pills, Didrocal® and medications taken weekly such as Fosamax® could easily be missed. Other medications not in a blister pack include insulin, inhalers, injections, patches, drops, creams, sprays.
· If the patient does not have a medication list or their medication vials with them and does not know their medications, ask them where they fill their prescriptions and call their pharmacy for the information and have the medication profile faxed. Or use the pharmacy information on the PIN profile to identify the name and phone number of the community pharmacy used. Ask if they use more than one pharmacy. (This is a good time to reinforce the importance of using one pharmacy).
· Make a photocopy of ALL home medications lists, blister pack lists, pharmacy profiles or Medication Administration Record (MAR) from another facility used to compile the BPMH. Put a patient label on the photocopy and keep as part of the permanent record. This will prevent duplication of effort for the next care provider (nurse, pharmacist, or physician).
· Regardless of the source of the medication list, always review each medication, dose and frequency with the patient. Don’t assume that the patient is taking the medications according to the label directions. Record each medication as it is taken at home on the BPMH. Document changes in the comments section of the Medication Reconciliation form.
· Ask the patient if they or their physician have changed a dose or stopped any medications recently. Ask open ended questions such as “Do you know why it was changed?” Or “How do you take this medication?”
· Ask if they see more than one physician (cardiologist, oncologist, family physician, etc.). This may help them remember medications related to a specific condition.
· Ask if there are any medications they take only sometimes when they need it. Determine how often they take them.
· Ask if there are any medications they do not need a prescription for that they take on a regular basis (e.g. ASA, vitamin, herbal products, and non-traditional remedies).
· Use medical conditions as a trigger to match medications (for example, ask about the use of inhalers for a patient with COPD, Insulin for a Type I Diabetic, Calcium and Vitamin D for a patient with osteoporosis).
· Prompt the patient for information regarding the use of creams, drops, sprays, patches, inhalers or injections (e.g. Vitamin B12, Fragmin®, Eligard®).
· Review the wellNET PIN profile to see if there are medications listed which the patient has failed to mention.
· Verify the accuracy of the BPMH with at least TWO sources of information. Possible sources of information include: patient, family members, community pharmacy, family physician, MAR from another facility, dosette or blister pack, medication vials or netCARE PIN profile.
Use this opportunity to educate the patient on the importance of using a medication wallet card and bringing their medications into the hospital or to physician office visits.
Instructions for Use of the
Medication Reconciliation and Physician’s Orders
This form serves a dual purpose; a medication history and physician order for home medications. It is to be completed for ALL patients on admission.
Procedures: (Nursing, Physician, Nurse Practitioner, Pharmacist)
· Put patient label in the designated area.
· If patient is not on any medications initial the box ‘No Prescribed home medications.’ Sign the form.
· In the ‘Best Possible Medication History (BPMH)’ section, list all prescription and over-the-counter (OTC) medications used. Include dose, route, and frequency. For medications used weekly, document the day given; for monthly injections, indicate last date of injection if known. Sign the form below the last medication entry.
· List vitamins and herbals that the client may take in the ‘Self Prescribed Medication’ section. See definition of Self Prescribed below.
· If there is inadequate space for all medications, use a second sheet and indicate the page number in the bottom right hand corner.
· Verify the BPMH with at least two information sources. Photocopy patient home medication list, blister pack or dosette labels, MAR or pharmacy profiles used. Attach patient name label to list and keep as part of the permanent record. In the section labeled ‘Information Source’ check ALL sources used.
· For patients transferred from another acute care facility, a BPMH must be completed listing the medications as taken at home prior to the patient’s admission to that facility. This is for information only. Transfer orders are written on the usual Physician’s Orders form.
· If the form is not used for admitting orders put a line through the Physician Reconciliation / Order of Home Medications section so that it cannot be used.
· Refer to the BPMH to reconcile home medications on discharge.
· The form is to be placed along side the usual ‘Physician’s Orders’ so that both sets of orders will be seen and processed.
THIS FORM CAN BE USED AS ADMITTING HOME MEDICATION ORDERS ONLY IF SIGNED BY THE PHYSICIAN OR NURSE PRACTITIONER.
Self Prescribed Medications: These are medications or supplements that the patient is taking to treat an illness (cold medications) or as part of a health promotion (vitamins/herbals) that will not impact the current hospital stay or management of an existing chronic disease. These medications will not be continued in hospital unless specifically requested by the patient or physician. Write these orders on the usual Physician’s orders form.
Prescriber Instructions: (Physician or Nurse Practitioner)
· Review each medication and initial the appropriate box.
o Initial ‘Continue’ box if the HOME medication dose, route and frequency are to continue as written.
o If there is any change in the HOME medication dose, route or frequency initial the ‘Change’ box, complete the reason for change in the ‘Reason for Discontinue/Change’ column, and write the revised order on the usual Physician’s Orders form.
o For any medications that are discontinued the ‘Discontinued’ box must be initialed. Write the reason for not ordering in the ‘Reason for Discontinue/Change’ column.
· Draw a line from the last medication ordered on the form to the physician signature box to prevent further medications from being added.
· Sign, date and time in the ‘Physician Signature’ box.
· Indicate on usual physician’s orders form to ‘see Med Rec form for orders’.
Any new medication orders must be written on
Physician’s Orders form.
Late Entries: (Nursing, Physician, Nurse Practitioner, Pharmacist)
Once the ‘Medication Reconciliation and Physician’s Orders’ form is signed by the physician any new medication information is to be recorded by writing “Late Entry” if there is room in the BPMH section, date and sign. Also write this new information in the Physician’s Orders to be reconciled. If there is no room in the original BPMH, start a new form indicating these are late additions. This may include additional medication information you receive from family members, dosage or frequency corrections discovered when further sources of information were accessed, or simply information the patient forgot to tell you previously.
Late additions which identify changes to a previous entry in the BPMH must be clearly documented. Cross reference by indicating “see new info below’ beside the medication entry which is being updated / changed.
If more modifications are required than space allows, start a second page, continue writing modifications in the BPMH column, but be sure to cross out the ‘Physician Reconciliation / Order of Home Medications’ column to prevent these late additions from being mistaken as medication orders.
Sign and date below your last entry.
‘Late Addition’ medications are NOT new medication orders. This is for information only. Inform the charge nurse of the new information. The charge nurse will then initiate follow-up with the responsible physician.
· If continued as at home, write the verbal order on the usual ‘Physician’s Orders’ form.
· If changed from home, write the verbal order and document the reason for the change if possible.
· If discontinued from home, document in ‘Comments’ section or in the Progress Notes on the ‘Physician’s Orders’ form.
PIN Profile (Pharmacy Information Network)
The completeness of the information is improving as more sources of information are entered into the provincial data base. You must read carefully the information provided and always look at the date the Rx was filled last. As physicians offices come on line, they may prescribe a medication but it has never been filled (there is no dispensing information on the PIN).
Value of the PIN profile:
• Provides a starting point to ask the patient what medication is taken and how often.
• Provides the name and phone number of the patient’s community pharmacy. Identifies multiple pharmacies.
• Provides name and phone number of prescribing physician.
Limitation of the PIN profile
• May be incomplete. May be missing transplant meds, cancer treatments.
• Currently does NOT always include dosing information.
• Does NOT include uninsured medications, OTC, herbals.
Caution: Do not make assumptions for dosing information based on the PIN profile. Review all information with the patient.
Roles and Responsibilities in Medicine/Surgery
Acute Care Charge RN:
– Review orders from ER.
– Ensure BPMH is completed.
– Reconcile orders with the BPMH. Bring discrepancies to the attention of the physician.
– Use Med Rec form and current medication profile to determine Medication Discharge Plan.
Bedside RN/LPN:
– Complete BPMH on patients transferred from another acute care setting or direct admits and on any patient from ER without a BPMH. Do not record medication history in the nursing database.
Physician / Nurse Practitioner:
– Verify home medication history with the patient.
– Make a decision about each medication on the list indicating that decision by initialing in the appropriate column (continue, discontinue, change).
– Document the reason for medications which are discontinued or changed in the reason column.
– Sign and date the form (making it acceptable as medication orders).
Pharmacist:
-Secondary check of order accuracy and completeness.
– Review appropriateness of therapy.
– Available for consult for patients with complex medication regimes and for patient teaching.
– On transfer admissions, available for consult when medications have been changed and insufficient information comes with the patient.
– On discharge, available to assist with complex medication regimes to improve communication to community pharmacists.
Medication Reconciliation on Discharge
Discharge reconciliation compares the MAR or Therapeutic Monitoring Profile with the Best Possible Medication History to determine the Medication Discharge Plan. If possible, the comparison should be completed the day prior to the patient discharge.