4/2/2018. Objectives. Victoria Stanislovaitis, PharmD. Medication Reconciliation (Med Rec) Victoria M. Stanislovaitis, PharmD. RockMED LTC Pharmacy

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1 Medication Reconciliation (Med Rec) Victoria M. Stanislovaitis, PharmD RockMED LTC Pharmacy Objectives Definitions Explain the importance of medication reconciliation Learn the duties and responsibilities of those who perform medication reconciliation Demonstrate an understanding of the medication reconciliation process Understand the importance of being thorough and preventing medication errors Comprehend the role the pharmacist plays in medication reconciliation Victoria Stanislovaitis, PharmD B.S. in Biochemistry from Millikin University in 2008 Doctor of Pharmacy (PharmD) from Midwestern University in 2011 Staff Pharmacist at Walgreens x 5 years Pediatric Clinical Pharmacist at CHOI x 2 years Adjunct Faculty at Midstate College in Peoria, IL in the Pharmacy Technician Diploma Program x 2 years LTC Pharmacist since November

2 Independent Pharmacy in Edgerton, WI Serving 60+ facilities Specialty unit dose packaging Delivery (daily and next day mail out) Hospice On call pharmacist 24/7 for emergencies Definitions Medication reconciliation The process of creating the most accurate list possible of all medications a patient is taking (including drug name, dose, frequency, and route) and comparing that list against the physician's admission, transfer, and/or discharge orders Goal: provide correct medications to prevent medication errors Medication errors Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient, or consumer Why Is Med Rec So Important? Done with transitions of care Studies show 60% of medication errors occur at transition of care But why? Not every facility has pharmacists, doctors, or nurses present Not enough resources/rushing 2

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4 Medication Errors Examples Birth control not having the route (PO) on directions patient assumed to insert it vaginally Directions: once daily; Once = 11 in Spanish; Med Pass Person Gave to Patient 11 times in a day Suppositories: Directions Not Clear to Patient; Pharmacy didn t put on directions: Unwrap and Insert Patient just inserted with foil wrapper still on Where Does Med Rec Happen? Hospitals Admission to inpatient Discharge To Home To LTC Long Term Care Admit from Rehab Hospital Home 4

5 Who Does Med Rec? Nurses Doctors Pharmacists Pharmacy residents Pharmacy technicians If trained/with special training Why Are Pharmacists so Important with Med Rec? Pharmacists are the medication experts Studies Study 1 Fewer errors found when a pharmacist (rather than MD) completes Med Rec 55 patients 353 discrepancies identified by pharmacists 58 of which were not identified by MD 5

6 Study 2 Decreased waiting time Faster dispensing time (versus when a RN does) Clarifying allergies and their reactions PCN allergy? What was rxn? Hives? Study 3 Decreased mortality rates with pharmacists In 2007 Researchers compiled data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14 clinical pharmacy services were compared with data from hospitals that did not have these services. 3,988 deaths avoided Study 4 Pharmacists identify more medication taken by the patient OTC, herbals Pharmacists contact out patient pharmacies more than RN 6

7 Sources of Medication Information Patient/family interview Medication bottles/vials Medication list Calling outpatient pharmacies like Walgreens, CVS, etc Government medication database clozapine Physician discharge summary Previous assisted living facility Four C s of Med Rec Collect Compare Correct Communicate What Do We Look For During Med Rec? Five Rights of Right Drug Right Patient Right Route Right Time Right Dose Ten Rights of Drug Administration Right Drug Right Patient Right Route Right Time/Frequency Right Dose Right Assessment Right to Refuse Right Patient Education Right Evaluation Right Documentation***** 7

8 Other Things We Look For During Med Rec Patient allergies Drug interactions Indication Frequency Duration All medications OTC and Prescribed Examples of What We Look For Right Patient Similar names, John Smith, DOB Right Time Lipitor 40 mg QHS = cholesterol is made at overnight Drug Interactions Simvastatin and amlodipine Max simvastatin dose 20 mg due to increased simvastatin levels, LFT s, etc Med Rec in Long Term Care When A Patient is Being Admitted to A New Facility All orders must be signed and dated by the prescriber (not RN) Orders must have the date the patient is being admitted so pharmacy can plan accordingly so patient can get their meds on time We need all of the patient s insurance cards, not just their Medicare card Running into issues with insurance If patient has a pill bottle at home, some insurances don t allow us to bill and fill medication 8

9 Key Things To Remember Everyone has different rules and regulations Nursing Protocols Medication Laws Facilities/Skilled Nursing/Assisted Living/Nursing Homes We must work as a team and understand each other; there may be times when we have conflicting rules, but we must follow the strictest rules Where Does Pharmacy Run Into Issues? Pharmacy laws Anytime an order is faxed to the pharmacy, it must have the date and the prescriber signature If the prescriber gives the order to an RN, the RN can fax it to us with prescriber signature or call it into the pharmacist Let s Practice Two medication reconciliations Two different patients One good One not so good 9

10 Patient Number 1 Patient 1 Patient 1 10

11 Patient 1 Example 2: Hot Mess Two medication lists sent to us One signed by prescriber, one not signed Conflicting Directions Duplicate Therapy Medication Omissions 11

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14 References Reeder T, Mutnick A. Pharmacist versus physician obtained medication histories. Am J Health Syst Pharm. 2008;65(9): [PubMed]\ Becerra Camargo J, Martinez Martinez F, Garcia Jimenez E. A multicentre, double blind, randomised, controlled, parallel group study of the effectiveness of a pharmacist acquired medication history in an emergency department. BMC Health Serv Res. 2013;13:337. doi: / [PMC free article] [PubMed] [Cross Ref] Nester T, Hale L. Effectiveness of a pharmacist acquired medication history in promoting patient safety. Am J Health Syst Pharm. 2002;59(22): [PubMed] Michels R, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm. 2003;60(19): [PubMed] Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy. 2007;27(4): [PubMed] Farley TM, Shelsky C, Powell S, et al. Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge. Int J Clin Pharm. 2014;36(2): [PMC free article] [PubMed] National Transitions of Care Coalition Available at: Accessed March 1, Rozich JD, Resar RK. Medication safety: one organization s approach to the challenge. J Clin Outcomes Manage. 2001;8(10): National Transitions of Care Coalition Care transition bundle: seven essential intervention categories Available at: Accessed March 1, Sanchez GM, Douglass MA, Mancuso MA. Revisiting Project Re Engineered Discharge (RED): the impact of a pharmacist telephone intervention on hospital readmission rates. Pharmacotherapy. 2015;35(9): doi: /phar [PubMed] [Cross Ref] Gil M, Mikaitis DK, Shier G, et al. Impact of a combined pharmacist and social worker program to reduce hospital readmissions. J Manag Care Pharm. 2013;19(7): [PubMed] What Questions Do You Have? 14