Transcript Jump Into MedRec: Improving BPMH Quality Across the

Jump into MedRec:
Improving BPMH Quality Across
the Continuum of Care
An interprofessional education collaboration by
TBRHSC clinical nurse specialists, interprofessional
educators, and pharmacists.
Through collaboration we are advancing patient safety at TBRHSC!
© Institute for Safe Medication Practices Canada 2012®
Welcome to the BPMH Training
Module!
• Estimated duration to complete module: 35 minutes
• Please note the following:
• The BPMH training PowerPoint is to be completed prior to attending
clinical placement at Thunder Bay Regional Health Sciences Centre.
• Review the “How to Guide for Nursing Staff” to access the Medication
Reconciliation Module in Meditech.
Please ensure your volume is turned up. While the
majority of the module is narrated, you can read the
slides if sound is not available.
© Institute for Safe Medication Practices Canada 2012®
Objectives
At the end of the session participants will:
• Learn how to obtain a BPMH using a systematic
process.
• Learn how to identify and document discrepancies
between sources of information.
• Apply the knowledge, tools, and resources offered
during the session to their own healthcare
environment.
© Institute for Safe Medication Practices Canada 2012®
A Grandfather
• An 83 year-old resident of a long-term
care facility was transferred to hospital for
management of dehydration.
• While in hospital, the following medication
was sent to pharmacy “K-Lor 20 mEq, 2
packs PO now and repeat in 4 hours”.
• The order was entered and processed and
the notation DC appeared on the profile.
© Institute for Safe Medication Practices Canada 2012®
Computer Profile
Discontinue
Medication Reconciliation and Medication Review: Complementary
Processes for Medication Safety in Long-Term Care. ISMP Canada Safety
Bulletin 2007; 7(9).
© Institute for Safe Medication Practices Canada 2012®
Unfortunately . . .
• Two days later, the resident was
discharged back to the LTC facility.
• Potassium chloride 40 mEq PO Q4H was
included in the medication orders and
administered for the next 17 days.
• At that time, the resident was re-admitted
to hospital with hyperkalemia (potassium
level > 9 mmol/L), dehydration, and
subsequently died.
© Institute for Safe Medication Practices Canada 2012®
What is Medication
Reconciliation?
• Goal:
• Prevent adverse drug events by implementing
a medication reconciliation process upon
admission, transfer, and discharge.
• Health-care providers work together with
patients/caregivers to ensure accurate and
comprehensive medication information is
communicated consistently across
transitions of care.
© Institute for Safe Medication Practices Canada 2012®
What is Medication
Reconciliation?
It involves:
• Completion of a thorough comprehensive
BPMH.
• Identifying and documenting discrepancies.
• Resolving the discrepancies, and
communicating all medication information
to the next care provider.
© Institute for Safe Medication Practices Canada 2012®
What is Best Possible
Medication History (BPMH)
A Best Possible Medication History (BPMH) is a
medication history obtained by a clinician which includes
a thorough history of all regular medication use
(prescribed and non-prescribed), using a number of
different sources of information.
The BPMH is different and more comprehensive than a
routine primary medication history.
Why is called the
‘Best Possible’?
Because . . . it’s the BEST you can do
with the information you can gather at
the time.
© Institute for Safe Medication Practices Canada 2012®
Why do we need to Implement
Medication Reconciliation?
• Accreditation Canada has identified
medication reconciliation as a required
organization practice (ROP).
• Thunder Bay Regional Health Sciences
Centre must implement the medication
reconciliation process in order to meet
Accreditation Canada requirements for
2014.
© Institute for Safe Medication Practices Canada 2012®
TBRHSC Case Example #1
• Patient admitted to a medical service at TBRHSC.
• Change in condition requiring admission to Critical
Care.
• On transfer to Critical Care, patient’s home
phenytoin (for seizure disorder) was accidentally
not prescribed.
• A few days later when patient was transferred
back to the medical service, phenytoin was still not
prescribed.
• Several days later, patient had a seizure due to
omission of home phenytoin medication.
© Institute for Safe Medication Practices Canada 2012®
Who Can Do A BPMH?
Prescribers/physicians, nurses, midwives,
pharmacists, pharmacy technicians, and other
healthcare professionals . . .
. . . who have been formally trained, who follow a
systematic process, who are conscientious,
responsible, and accountable . . .
. . . in partnership with the patient/resident/client
and family/caregiver.
© Institute for Safe Medication Practices Canada 2012®
Clinical Responsibility
• It is not about changing your scope of practice.
• Responsibility for assessing the clinical
appropriateness of each medication continues to
be multidisciplinary.
• If you see something that concerns you,
communicate/document your concerns to the
prescriber.
© Institute for Safe Medication Practices Canada 2012®
When to do the BPMH
• The nurse will obtain the BPMH within
24-hours of admission to an inpatient unit.
• Some departments have different
timeframes to obtain the BPMH:
• Preadmission clinic nurse will obtain the
BPMH at the pre-operative visit.
• Critical care 48-72 hr. (often patients are
intubated).
• Emergency Department 12-hr. of admission
© Institute for Safe Medication Practices Canada 2012®
How to Complete a Thorough BPMH
1. Interview
2. Compare
3. Identify
4. Document any
discrepancies
© Institute for Safe Medication Practices Canada 2012®
Step 1: BPMH Interview:
A Systematic Process
Talk and listen to patient/family/caregiver:
• Ensure environment conducive to
interview.
• Ask for current medication list.
• Consider current actual medication
use – not what they were prescribed.
• Ask open ended questions i.e., “how
do you take this?”
© Institute for Safe Medication Practices Canada 2012®
BPMH Interview:
A Systematic Process (continued)
• Be proactive gather information ahead of time.
• Time commitment: goal 15 to 20 minutes.
• Prompt questions about all medications.
• Prompt questions about unique dosage forms.
• Use medical conditions as a trigger when
possible.
• Ask if have taken antibiotics in past 3-months.
© Institute for Safe Medication Practices Canada 2012®
BPMH Interview:
A Systematic Process (continued)
• Obtain community pharmacy information.
• Ask about:
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Prescriptions (patches, creams, eye drops, inhalers)
Over-the-counter (OTC) medications
Herbal and other natural remedies
Vitamins and minerals
Recreational drugs
Samples
Clinical trial medications.
• Don’t make assumptions.
• Use ‘head-to-toe’ review of systems approach
• Use the BPMH interview tool.
© Institute for Safe Medication Practices Canada 2012®
Step 2: BPMH Compare Sources of
Information
Multiple sources
• Medication vials
• Blister packs
•Community pharmacy
list
• Hospital discharge
summary
• Long-term care MAR
• Electronic records
Compare
Patient and Family
Interview
• When and where
possible
• Determine what the
patient is ACTUALLY
taking.
Identify & document discrepancies
between the sources of information
BPMH
© Institute for Safe Medication Practices Canada 2012®
Sources of Information
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Patient (recall)
Family/caregiver (recall)
Medication vials
Bubble pack/dosette
Discharge orders from other
facility (including MAR)
Patient own or previous
medication list
Community pharmacy
Ontario Drug Benefits Drug
Profile viewer (ODB DPV)
Other?
© Institute for Safe Medication Practices Canada 2012®
Medication Information
From Multiple Sources
• All sources of information are NOT created equally.
• START with the most recent sources of info.
• Know the limitations of your sources.
© Institute for Safe Medication Practices Canada 2012®
Community Pharmacy Profile
• Ask the patient if they use more than one pharmacy.
• When calling the pharmacy verify you have the
correct patient using another piece of information
besides the name (address, date-of-birth).
• Confirm with the patient if there any other
medications they are taking (prescriptions, PRNs,
over-the-counter [OTCs], herbals, vitamins, etc.).
• Confirm if they are taking the medications differently
than prescribed.
• Confirm the allergies that the community pharmacy
has on record.
© Institute for Safe Medication Practices Canada 2012®
Medication Vials/Blister Packs
• Check the patient’s name
on the vial.
• Check the patient’s name on the
blister pack.
• Check the date on the vial.
• Check the date on the blister
pack (determine if any changes
have been made to the patient’s
medications since the blister pack
has been filled).
• Open the vials and make
sure what is in the vial
matches the label.
• Ask the patient how they
are taking the medication –
compare it to the
instructions on the vial.
• Do not assume patient is taking
all of the medications in the blister
pack.
• Ask about medications that
cannot fit inside the pack, e.g.,
puffers, patches, eye/ear drops,
injectables, etc.
• Ask about PRN medications.
© Institute for Safe Medication Practices Canada 2012®
Step 3: What If Two Sources
Of Information Don’t Match?
• Verify medications using at least two sources
• Identify the discrepancies:
• Only one of them is what is actually happening.
• Find out as much as you can from the sources of
information, call pharmacy, start-stop dates –
investigate further.
• Document the discrepancies
• Comments section is used for communicating
these types of discrepancies.
© Institute for Safe Medication Practices Canada 2012®
Step 4: Document BPMH to…
• Ensure that a standardized,
comprehensive process is used.
• Documented information = better patient
outcomes.
• Serves as historical reference.
© Institute for Safe Medication Practices Canada 2012®
Challenges in Obtaining a
BPMH
 Belief – physician has
information
 Unfamiliar with medications
and names
 Difficulty re-calling
 Medicated patients (sedated,
confused)
 Disease affects mental status
 Language barrier
 Hearing impairment
 Elderly patients
 Caregiver administers or sets
up medications
 Medication vials or list
unavailable
 If patient can not remember a
medication or if clarification is
needed:
 Get a description of the
medication from the patient or
family member (form, strength,
size, shape, colour, markings)
 Contact family member that
could possibly bring in the
medication or read it over the
phone
 Call the patient’s pharmacy
 Review previous medical
records
© Institute for Safe Medication Practices Canada 2012®
Helpful Documentation Tips
• Pay attention to high alert drugs (e.g.
coumadins, insulin, opiates, psychotropics,
etc.).
• Liquids - record the concentration of the
liquid (mg/mL).
• Don’t forget injectables (vitamin B12,
methotrexate, psychotropics, etc.).
© Institute for Safe Medication Practices Canada 2012®
Helpful Documentation Tips
• Ensure the proper formulation of the
medication is ordered, long acting vs. short
acting (CR, XR, ER, LA).
• Be mindful that certain medications have to
be administered at exact times (Sinemet®
[carbiopa-levodopa]).
• Be aware of generic/trade names,
autosubstitutions.
• Do not use dangerous abbreviations.
© Institute for Safe Medication Practices Canada 2012®
Best Possible Medication History
…a systematic process,
…the cornerstone of medication reconciliation,
…includes identifying and documenting
discrepancies
…uses at least two sources of information to create
a Best Possible Medication History
© Institute for Safe Medication Practices Canada 2012®
Admission Medication
Reconciliation Form
• Once admission
orders are processed
and BPMH is
obtained and
documented, the
Admission
Medication
Reconciliation form
will be printed and
put on the chart by
nurse/pharmacist.
•
This form will
contain the
patients home
medications in the
left hand column
and medications
prescribed while
in hospital in the
right hand column
© Institute for Safe Medication Practices Canada 2012®
Home Medication Post-op Order
Form
1.
4.
The patient will come to
Surgical Day Care with a
Pre-op package entitled
“Home Medication Postop Order Form” which
lists the patients home
medications.
The form will be
signed and
dated by the
surgeon and
then faxed to the
Pharmacy
Department and
put in the
Physician Order
section of the
patient’s chart.
2.
Post-operatively the surgeon
will review each home
medication and select “yes”
for medications that are to be
continued post-op and select
“no” for medications not to
be continued post-op.
3.
For medications not to
be continued post-op
indicate reason in the
medication section.
Indicate reason for not continuing
medication(s) post-op in this section.
© Institute for Safe Medication Practices Canada 2012®
Medication Order for Patients
Transferred Between Programs
1.
The Intensivist will
review the form
“Medication Order for
Patients Transferred
Between Programs
Within Facility”.
4.
The form will be
signed and
dated by the
Intensivist and
then faxed to the
Pharmacy
Department and
put in the
Physician Order
section of the
patient’s chart.
2.
The Intensivist will review
each current medication and
select “yes” for medication to
be continued or “no” for
medication that is not to be
continued for the patient
transferred to the ward.
3.
For medications not to
be continued upon
transfer to the ward,
indicate reason in the
medication section.
Indicate reason for not continuing
medication(s) post-op in this section.
© Institute for Safe Medication Practices Canada 2012®
Medication Reconciliation - Review
It involves:
Completion of a thorough comprehensive BPMH.
Identifying and documenting discrepancies.
Resolving the discrepancies, and communicating all
medication information to the next care provider.
Please direct any questions to
your clinical instructor.
© Institute for Safe Medication Practices Canada 2012®
Thank-you!
© Institute for Safe Medication Practices Canada 2012®