Transcript Medication Reconciliation by a Pharmacist

Engaging the C-suite to Advance
Pharmacy Practice
Providing quality patient care through
progressive pharmacy practice
Ensuring the Accuracy of the
Medication List
Medication Reconciliation/Transitions of Care
Medication-Focused Transitions of Care
Initiatives
CHF
ED PTA Medication
List High Risk
Admits
Ensuring
Accurate
Medication
Handoffs
Inpatient
Medication
Reconciliation
Validation of PTA
medication list for
high risk patients
PTA=Prior to Admission
High Risk
Patients
Transition to
SNF
Validation of Prior to Admission
Medication (PTA) List
Pharmacist PTA Medication List Validation- High
Risk Pts
1. Duplicates deleted
2. High Risk Patients PTA List Validation
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•
•
•
CHF
Therapeutic Class duplicates
Greater than 10 chronic meds (not PRNs)
Professional judgment
N=2000pts
Drug Related Problems
Resolved=16,000
Evaluation process: pt
medication history,
contact community
pharmacy, contact MD(s)
• Resolve variances on PTA list
and inpatient medication
orders
Prior to Admission (PTA) Medication List-Pharmacist Evaluation
Drug Related Problems (DRP) Resolved in High Risk Pts
April-August 2012
16,000 drug-related problems resolved (2,100 pts):
7.5 DRPs/pt)
21% of inpatient orders were changed due to PTA discrepancies
Recommended
DC/initiation of
therapy
Patient
0%
7%
Education
2%
Extraneous
medication
10%
Wrong
dose/dose
adjustments
12%
40% of resolved DRP were classified as
life threatening or serious/significant
Omission of
medication
46%
Wrong freq/
instructions
23%
Transitions of Care
• 60% of resolved DRPs were classified
serious/significant or life-threatening
PTA med
lists
reviewed
on admit
Hospital
Meds
reconcile
d on
admit
Med rec
done at
time of
Discharge*
PostDischarge
follow-up call
performed**
# of Patients
Average DRP
per patient
6
Post-Discharge Follow Up
Total
n=60**
% of potential re-hospitalizations prevented*
% of medications taken as prescribed vs. medications
prescribed
# of medications that patients continued to take even
though they were not on the d/c medication list**
23%
80%
70
* # based on physician validation
**Excludes vitamins, minerals, herbals, and/or supplements
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