Medication Reconciliation

Define the term medication. Define medication reconciliation. Describe the potential barriers to obtaining an accurate medication list and resolution strategies to overcome these barriers. Discuss the role of patient education related to patient safety.

.is the process of reconciling a patient s medication list at transitions in care; Med Rec for short Helps to ensure all medications are accurate on admission to a hospital or nursing home, at inpatient transfers, on discharge, and in the community pharmacy or outpatient setting. Joint Commission on Accreditation of Health Care Organizations Sentinel Event Alert. Using medication reconciliation to prevent errors. Issue 35. January 25, 2006. www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/(accessed 8/20/2014)

the process of checking against another for accuracy to account for http://www.merriam-webster.com/dictionary/reconcile

Prescription medication sources: Community pharmacies Mail order pharmacies Specialty pharmacies Compounding pharmacies Prescription assistance programs Free clinics Provider samples Infusion or dialysis centers Out of country Over-the-counter (OTC) meds Vitamins, herbals Dietary supplements Nutraceuticals Borrowed meds Illicit medications Vaccines Implanted/depot medications Diagnostic and contrast agents Radioactive therapies Respiratory therapy medications

Medication reconciliation is.a process of identifying the most accurate list of all medications a patient is taking including name, dosage, frequency, and route and using this list to provide correct medications for patients anywhere within the health care system. 100,000 Lives Campaign Institute for Healthcare Improvement 2007 http://www.ihi.org/knowledge/pages/tools/medicationreconciliationreview.aspx

Medication reconciliation.. is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. Transitions in care include changes in setting, service, practitioner or level of care. Joint Commission on Accreditation of Health Care Organizations Sentinel Event Alert. Using medication reconciliation to prevent errors. Issue 35. January 25, 2006. www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/(accessed 8/20/2014)

2005: Medication reconciliation selected as one of the National Patient Safety Goals (NPSG) NPSG #8..to accurately and completely reconcile medications across the continuum of care Organizations struggled to develop and implement effective and efficient processes. 2009: Evaluated but not affecting accreditation until effective in 2011 2011: New version requires organizations to. maintain and communicate accurate medication information and compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies. Joint Commission on Accreditation of Health Care Organizations Sentinel Event Alert. Using medication reconciliation to prevent errors. Issue 35. January 25, 2006. www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/(accessed 8/20/2014)

The Joint Commission s continuum of care refers to all care settings, including: Ambulatory Care Emergency and Urgent Care Home and Home Care Inpatient Services Long-term Care

Occurs when a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies. A good faith effort to collect this information is recognized as meeting the intent of the requirement.

It belongs to. The Nurse? The Provider? The Pharmacist? The Medical Assistant? Others? The Patient?... Everyone can play a role to ensure an accurate patient medication list.

Patient Self, caregiver, family Pharmacies Community, Mail order, Specialty, Free Clinic Providers Primary Care Provider, Specialists, etc. Health Information Exchanges HealthInfoNet in Maine Health systems, EMT

Time? Workflow? Fear? Authority? Consensus? Different Medical Record Systems? (paper, electronic)

Verification Collection of the medication history Clarification Ensure that medications and doses are appropriate Reconciliation Documentation of changes in the orders Institute for Healthcare Improvement 2007 http://www.ihi.org/knowledge/pages/tools/medicationreconciliationreview.aspx

Review list for duplicate therapies Document discontinued, omitted therapies Examine medications and patient list Obtain list of medications actually filled from the pharmacy or refill history dates Create a clean working list

Assumptions: Printed list, all medication bottles, tubes, etc. Open-ended, non-judgmental questions Tell me how you use this medication (show) Do you take this with food? What time of day? Have you had any changes in your medications? In order to provide the best care for you, I have to ask some personal questions. This is not meant as a judgment. Do you obtain medications from anyone else, use marijuana, stimulants, street drugs..?

Educate at appropriate health literacy level Accommodate for vision, hearing and language barriers Encourage patient involvement in communication about their medications Encourage self-advocacy for their own safety

Who could you invite to be on your team? How can you advocate for the patient? Use your organization and community resources Think collaboratively; recruit others

Nellie M., 79 y/o female, admitted from local assisted living home last evening for wrist fracture as a result of a fall HPI: This is the 2 nd fall noted in one month. PMH: HTN, CHF, mild dementia, osteoarthritis Medications: (per electronic health system records) Metoprolol 50 mg PO daily Furosemide 40 mg PO daily Lisinopril 10 mg PO daily Donepezil 5 mg PO qhs Acetaminophen 1,000 mg PO tid prn

You are on the Transition of Care team.. Visiting Nellie s home 3 days after discharge From interview with patient and daughter: Nellie takes her furosemide dose at dinner (evening) She gets up in middle of the night to go to the bathroom Nellie takes her acetaminophen for her osteoarthritis Usually takes at bedtime because of joint AM stiffness Medication Inventory: Takes 2 tablets PO nightly from a bulk bottle of Tylenol PM Each tab contains: Acetaminophen 500 mg with diphenhydramine 25 mg

Night-time awakening for trip to bathroom Diuretic taken late in day Electronic records technically indicating daily but need to know what time of day Osteoarthritis Unintentional purchase of additional ingredient Diphenhydramine; on BEERS list - sedating Anticholinergic side effects: dizziness, dry mouth, falls, dry eyes, confusion, urinary retention, constipation http://www.americangeriatrics.org/files/documents/beers/2012beerscriteria_jags.pdf

Furosemide: Change to AM administration bedtime awakening; risk of fall Acetaminophen: Discontinue use of combination product Use single-ingredient acetaminophen Communication: Include findings in visit note Update medication listing for both inpatient and outpatient systems Alert provider(s)

Sam F., 67 y/o male, recently discharged from hospital to his own home after admission for chest pain HPI: Found to be in atrial fibrillation this admission PMH: HTN, dyslipidemia, mildly obese, GERD, DMII Medications: (per electronic record) Atenolol 50 PO daily Atorvastatin 20 mg PO daily (was changed from simvastatin 10 mg) Metformin 1,000 mg PO bid with breakfast and supper Lisinopril 20 mg PO daily Omeprazole 20 mg PO daily Glyburide 10 mg PO bid Warfarin 5 mg PO daily

Sam was discharged four days ago and you, the home care nurse, are visiting with Sam After reviewing the medications, his lists, and the discharge summary you notice the following discrepancies: He ran out of metformin and he says he has not called yet for a refill He uses a pill organizer but you notice there is atorvastatin and simvastatin in it

Keep the patient in focus Advocate for resolving found discrepancies Be fearless in resolution Avoid temptation to blame Be a fixer Engage the patient in the process

Which of the following sources of medications is often forgotten when considering the complete medication list for patients? a) Infusion center medications b) Over-the-counter medications c) Specialty pharmacy medications d) Patient Assistance or Sample medications e) All of the above are often forgotten.

Different information from different sources may be a barrier to medication reconciliation. Which of the following sources are helpful in obtaining a more complete and accurate medication history? a) The patient's community pharmacy b) The patient (and any list they may carry) c) The Health Information Exchange d) The patient's caregiver and/or family. e) All of the above.

True or False? Educating and supporting patients in various strategies to maintain their active, complete list of medications, will contribute to improvements in medication safety. a) True b) False

In the 2014 Hospital National Patient Safety Goals, The Joint Commission notes that ' is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications.' Which of the following best describes this? a) Medical Transcription b) Admission orders c) Discharge orders d) Medication Reconciliation e) Chart/MAR 24 hour review