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Medication Reconciliation 2013
Medication Reconciliation
2
What is medication reconciliation?
 Active decision about medication requirements during a transition
of care after reviewing home medications for possible drug-drug
interactions, drug duplications, dosing errors, or omissions[1]



Adding a new medication
Stopping an existing medication
Changing an existing medication (dose and/or frequency)
 Medication reconciliation should be considered at major
transitions of patient care


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
Ambulatory facility/ED visit
Admission to hospital/other facility
Transfer to a different level of care in same facility
Discharge from hospital/other facility
Medication Reconciliation Facts
3
Why is medication reconciliation important?
 2,022 reports of medication reconciliation errors from September
2004 to July 2005 reported to US Pharmacopeia (USP)[2]



22% occur at admission
66% occur at transition in level of care
12% occur at discharge
 1.5 million preventable adverse drug events (ADEs) occur annually
as a result of medication errors

$3 billion per year cost associated with preventable ADEs
 50% of all hospital-related medication errors and 20% of all ADEs
result from poor communication at the transitions of care[3,4]
 ADEs result in 2.5% of ED visits for all unintentional injuries and
6.7% of those leading to hospitalization[5]
Medication Reconciliation
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Why is medication reconciliation required?
 Quality of care:
 reduce adverse events
 lower cost
 Professionalism:
 prevent errors in care
 Regulatory:
 The Joint Commission requirement
UCI Med Reconciliation Process
5
 Obtain an accurate home medication list at start of
patient encounter by




Physician/NP/PA
Nurse
Pharmacist
MA
 Use various tools in Quest for viewing/updating home
medication list and inpatient medication list for
reconciliation at major transitions of care
UCI Med Reconciliation Process
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What features does each tool have for medication list?
OMR
Rx Writer OR Manager Clinical Summary Tab
(ORM)
View home
medications
View home
medications
View home
medications
Update home
medications
Update home
medications
Update home
medications
Rx new home
medications
Rx new home
medications
Order inpatient
medications
Med Reconciliation View
View home
medications
View inpatient
medications
Orders Tab
Pharmacy View
View inpatient
medications
Manage inpatient
medications
Order
icon
Order inpatient
medications
UCI Med Reconciliation Process
7
Select your primary role:
 Adult patient care
 Neonatal patient care
UCI Process - Adult Patient Care
8
Admission to hospital
Obtain/document medication Hx
Physician/NP/PA gets medication
Hx from patient and Quest tools
and documents medication list in
H&P and/or OMR
Everyone has a role
Nurse gets medication Hx from
patient, H&P, and Quest tools and
documents medication list in OMR
with status of review
Reconcile home/inpatient medication
Physician/NP/PA reconciles home
medications with inpatient orders
in Order Reconciliation Manager
(ORM) within 24 h of admission
Documenting Home Medications
9
Updating the home medication list in Quest tools maintains a
consistent list of home medications that can be referenced in
the Clinical Summary Medication Reconciliation view
Status of home medication list is
indicated
New Quest Tools - OMR
10
+Add home medication
Home Med Review status
Update status of home medication list:
taking, not taking, unknown, or incomplete
Edit Pharmacy info
Mark as reviewed
? Needs follow-up
for incomplete info
No longer taking
Edit medication
dose or frequency
New Quest Tools - ORM
11
Select here for admission reconciliation.
Status of medication reconciliation displays
New Quest Tools - ORM
12
=Home medication list (in OMR) not done
=Home medication list (in OMR) incomplete
=Home medication list (in OMR) complete
If home medication list needs editing, it can
be done by using +Enter function, launching
OMR, or editing each drug individually
Floating menu arrow
Only works if home medication list was
complete and all medications are reconciled;
otherwise, it will save as “incomplete”
Admission Reconciliation
[Expanded View]
Floating menu arrow
Convert to inpatient order=
Stop/hold on admission=
Reconciliation options
for home medications
appear after hovering
over floating menu
arrow (see previous
slide)
13
Change dose/frequency or alternative drug
Admission Reconciliation
14
If there is an existing inpatient order, it will match up with closest
home medication for reconciliation
Home Medications
Inpatient Medications
Admission Reconciliation
15
All home medications reconciled
Home Medications
Inpatient Medications
Held on admission
Patient was no longer taking this
drug, so it becomes crossed out
Continued as inpatient order
Admission Reconciliation
16
Enter additional admission medications
Discharge Reconciliation
17
Discharge Reconciliation
18
Use Discharge Note to launch discharge reconciliation (ORM)
Discharge Reconciliation
19
Launch discharge medication reconciliation (ORM) from
new Discharge Note
New Quest Tools - ORM
20
Discharge medication reconciliation
Select here for discharge reconciliation.
Status of medication reconciliation displays
Discharge Reconciliation
21
ITEMS TO RECONCILE= active inpatient
and pre-admission medications
e-Rx new discharge prescriptions here
If home medications prior to admission
were incomplete, add or edit here
After discharge reconciliation, the new
home medication list at discharge will
display on right side column
Discharge Reconciliation
22
There are also quick action buttons for each medication in Discharge Reconciliation that
are only enabled if there is a match in Prescription Writer for “quick prescription”:
Continue at home w/o Rx
“quick” discharge e-Rx
Not required or stop
If not enabled, you can still use the menu options to reconcile or prescribe:
Discharge Reconciliation
23
Home medication that was not
continued as inpatient order
Home medication that was
converted to inpatient order
Discharge reconciliation
options for pre-admission
home medication
Discharge reconciliation options
for inpatient medication
New Quest Tools - ORM
24
Choose expanded view in Format Layout to see all drugs
House/pill = home medication
Indicates (2) variations of same drug
House/pill = home medication
Pill indicates inpatient medication
New Quest Tools - ORM
25
Choose expanded view in Format Layout to see all drugs
House/pill = home medication
Both
versions expanded
Inpatient medication
Discharge Reconciliation
26
Discharge medication reconciliation actions:
 Tylenol was not ordered as inpatient drug but resumed at discharge
 Oral Dilantin prior to admission was converted to IV as inpatient order and then
back to oral with e-Rx at discharge
 IV Dilantin ordered as inpatient was not continued at discharge
Inpatient IV Dilantin crossed off
since not continued at discharge
Pre-admission oral Dilantin is
crossed off since new e-Rx created
at discharge
Discharge Reconciliation
27
Add discharge medication instructions in note after ORM
Click to update discharge medication list
is “complete”
in Discharge Note
Continue Home Medications
Tylenol 325 mg, 2 tablets every 4 hours as needed for pain or fever
Instruction Categories:
Continue Home Medications
•These Home Medications Are Not Changed
New Prescription
Dilantin extended release 30 mg, 1 capsule at bedtime
Sent to CVS, Orange (714) 555-5500
•These Home Medications Are Changed
New Prescription(s)
Stop These Home Medications
Required for Discharge Instructions to print. Will only autocheck if ORM is “complete”; otherwise, selection will clear
Discharge to Another Facility
28
Discharge to another facility does not require ORM
Select to open
active inpatient
orders
Required for Discharge Instructions to print
Printing Discharge Medications
29
Patient Discharge Instructions will not print until:
 the status of medication reconciliation is complete and verified
by Pharmacy for patients going to home, B&C, AL, etc. or
 Discharge Note indicates that transfer orders are “complete” for
patients discharging to another facility (SNF, LTAC, or other acute
care setting).
 New prescriptions or any updates to the medication list after the
status of medication reconciliation is completed will cause it to
become “incomplete” again
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
Discharge medication reconciliation needs to be re-done for any new Rx
Discharge medication list needs to be refreshed in Discharge Note
Re-do Discharge Reconciliation
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A reconciliation can be reset to incomplete if saved in
error or additional information was received. Re-launch
ORM:
1) Select “View/Maintain History” tab
2) Select “Discharge” Reconciliation Type
3) Click “Set to Incomplete” and return to
“Reconciliation Orders” tab
Summary of Key Points
31
Admission Medication History:


You can update the home medication
list via OMR while in the H&P note
and pull that list into your note.
Indicates the home medication list,
collected by the nurse, is complete
Medication Reconciliation:


Admission reconciliation is to be done
within 24 hours of admit
Remember to hover over the
medication list to use the floating
menu arrow to select reconciliation
options
Summary of Key Points
32
Discharge:


Discharge medication reconciliation (ORM) automatically updates
Prescription Writer and the medication list on the patient’s
Discharge Instructions
In the Discharge Note for patients transferred to another facility,
you are directed to review and select appropriate current orders to
be continued.
•
•
This constitutes the Discharge Order/Treatment Plan that includes
medications
Medication reconciliation (ORM) is not done on these types of
discharges
Summary of Key Points
33
Discharge (cont.):

New prescriptions or edits in Prescription Writer will reset the
discharge medication reconciliation to an incomplete status.
•
Return to the Discharge Note,
Launch medication reconciliation (ORM) and complete it,
•
“Refresh” medication list in the Discharge Note
•

Nursing will not be able to discharge the patient until medication
reconciliation and Pharmacy review is complete.
•
Discharge Instructions will not print until reconciliation is complete
Medication Reconciliation - Adult
34
Please make selection:
 End training
 Review Adult patient care admission medication reconciliation
 Review Adult patient care discharge medication reconciliation
 Neonatal patient care
UCI Process - Neonatal Care
35
Admission to hospital
Obtain/document medication Hx
If transfer, physician/NP/PA gets
medication Hx from family and/or
transfer records and documents
medication list in H&P and/or OMR
Everyone has a role
If admitted from home, nurse gets
medication Hx from family, H&P,
and QUEST tools and documents
medication list in OMR with status
of review
Reconcile home/inpatient medication
Physician/NP/PA uses medication
Hx to order inpatient medications
Documenting Home Medications
36
Updating the home medication list in Quest tools maintains a
consistent list of home medications that can be referenced in
the Clinical Summary Medication Reconciliation view
Status of home medication list is
indicated
New Quest Tools - OMR
37
+Add home medication
Home Med Review status
Update status of home medication list:
taking, not taking, unknown, or incomplete
Edit Pharmacy info
Mark as reviewed
? Needs follow-up
for incomplete info
No longer taking
Edit medication
dose or frequency
Discharge Medication
Reconciliation - ORM
38
Launch discharge medication reconciliation
Select here for discharge reconciliation.
Status of medication reconciliation displays
Discharge Reconciliation
39
ITEMS TO RECONCILE= active inpatient
and pre-admission medications
e-Rx new discharge prescriptions here
If home medications prior to admission
were incomplete, add or edit here
After discharge reconciliation, the new
home medication list at discharge will
display on right side column
Discharge Reconciliation
40
There are also quick action buttons for each medication in Discharge Reconciliation that
are only enabled if there is a match in Prescription Writer for “quick prescription”:
Continue at home w/o Rx
“quick” discharge e-Rx
Not required or stop
If not enabled, you can still use the menu options to reconcile or prescribe:
Discharge Reconciliation
41
Home medication that was not
continued as inpatient order
Home medication that was
converted to inpatient order
Discharge reconciliation
options for pre-admission
home medication
Discharge reconciliation options
for inpatient medication
New Quest Tools - ORM
42
Choose expanded view in Format Layout to see all drugs
House/pill = home medication
Indicates (2) variations of same drug
House/pill = home medication
Pill indicates inpatient medication
New Quest Tools - ORM
43
Choose expanded view in Format Layout to see all drugs
House/pill = home medication
Both
versions expanded
Inpatient medication
Discharge Reconciliation
44
Discharge medication reconciliation actions:
 Tylenol was not ordered as inpatient drug but resumed at discharge
 Oral Dilantin prior to admission was converted to IV as inpatient order and then
back to oral with e-Rx at discharge
 IV Dilantin ordered as inpatient was not continued at discharge
Inpatient IV Dilantin crossed off
since not continued at discharge
Pre-admission oral Dilantin is
crossed off since new e-Rx created
at discharge
Re-do Discharge Reconciliation
45
A reconciliation can be reset to incomplete if saved in
error or additional information was received. Re-launch
ORM:
1) Select “View/Maintain History” tab
2) Select “Discharge” Reconciliation Type
3) Click “Set to Incomplete” and return to
“Reconciliation Orders” tab
Medication Reconciliation Neonatal
46
Please make selection:
 End training
 Review Adult patient care admission medication reconciliation
 Review Adult patient care discharge medication reconciliation
 Review Neonatal patient care
References
47
[1] Pentecost MJ. "Improving health care quality: current concepts," Permanente Journal, 2007 Winter;
11(1): 75-8. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3061389/ . Accessed May 13,
2013.
[2] The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alert. Issue
35. January 25, 2006. Available at: http://www. jointcommission.org/assets/1/18/SEA_35.PDF.
Accessed May 13, 2013.
[3] Institute for Healthcare Improvement. 5 Million Lives: Preventing Adverse Drug Events (Medication
Reconciliation): How-to Guide. Available at:
http://www.ihi.org/IHI/Programs/Campaign/ADEsMedReconciliation.htm. Published Oct. 1, 2008.
Accessed May 13, 2013.
[4] The Joint Commission. 2011 National Patient Safety Goals. Available at:
http://www.jointcommission.org/assets/1/6/NPSG_EPs_Scoring_ HAP_20110706.pdf. Accessed May
13, 2013.
[5] Budnitz DS, Pollock DA, Weidenbach KN, et al. “National surveillance of emergency department visits
for outpatient adverse drug events,” JAMA, 2006; 296: 1858-66.