Transcript SRC education (new form) - Communities of Practice

Medication Reconciliation
Preventing adverse drug events one patient at a
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accessed through Title Master Slide
Linda Cawthorn, RN, MN (can)
Kim Spiers, BScPharm
Shelly Proft, BScPharm
Update date on title master slide
Objectives
•
Background Information
•
Define Medication Reconciliation
•
Instructions for completing the Med Rec Form
•
Case Study
•
How to take a medication history
•
Roles and responsibilities
•
Case Study
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Accreditation Standards
•
•
Medication Reconciliation is a new Canadian Council on
Health Services Accreditation Standard
•
“Reconcile the patient’s medications upon admission, and
with the involvement of the patient”
•
“Reconcile medications with the patient at referral or transfer
and communicate the patient’s medications to the next
provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization”
Enhances professional practice standards for the College of Physicians
and Surgeons, CARNA, CLPNA, and College of Pharmacists.
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Evidence from Literature
•
An adverse events among medical patients study
showed an overall incidence of adverse event of 23% for
discharged patients from a medical unit with 72% of the
events being adverse drug events. [i]
•
Implementation of medication reconciliation along with
other interventions decreased the rate of medication
errors by 70% and adverse drug events by 15%, over a
seven month period.[ii]
[i] Forester, A., Clark, H., Menard, A., Dupuis, N., Chernish, R., Chandok, N., Khan, A., van
Walraven, C. (2004) Adverse events among medical patients after discharge from hospital.
CMAJ, 170 (3).
[ii] Michels RD, Meisel S. Program using pharmacy technicians to obtain medication
histories. Am J Health Syst Pharm 2003;60:1982-1986
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Evidence from Literature
•
Implementation in a surgical population reduced
potential adverse drug events by 80% within three
months of implementation.[i]
•
For those with no missing medications, drug related
problems after discharge were reduced from 85% with
original prescription process, to 35%.[ii]
[i] Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag
Health Care 2004;13(1):53-59
[ii] Poole DL, Chainakul MP, Graham L. Medication reconciliation: A hospital
necessity in promoting a safe hospital discharge. J Healthc Qual (NAHQ) 2006
May/June
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Transitions in Care
Emergency
Room
Critical
Care Unit
Inpatient
Unit
Operating
Room
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Transitional
Care Unit
Rural
Facility
Residential
Facility
Home
Community
Medication Reconciliation-What is it?
•
A formal process of:
- Obtaining a complete and accurate list of each patient’s current home
medications (name, dosage, frequency, route).
•
Using the information obtained for physicians to write the admission
orders.
•
Documenting reasons why home medications are changed or
discontinued.
•
Bringing discrepancies to the attention of the prescriber and ensuring
changes are made to the orders, when appropriate.
•
Referring back to the information obtained to write transfer and
discharge orders.
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Key Benefits
• Improves patient safety and reduces errors.
• Helps obtain the best possible medication history.
• Enhances patient centered care by involving the patient in
obtaining the BPMH.
• Enhances communication between all care providers across all
settings.
• Matches in-house dose, frequency and route with at-home dose or
facilitates proper documentation if change is required.
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Key Benefits (cont’d)
• Prevents inadvertent omission of home medications.
• Prevents failure to restart home medications following
transfer and discharge.
• Prevents duplicate therapy at discharge from brand and
generic name usage or formulary substitutions made
while in hospital.
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Why should we do this?
Accuracy and Patient Safety!
Improve Discharge
Medication List
Improve Ambulatory
Medication List
Improved
Accuracy of
Medication List
Improve
Admission
Medication List
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Who?
Any patient who receives a treatment, procedure
or medication in a health care setting
Includes ER visits, admitted patients, day procedures, out-patient procedures,
radiology procedures (with medications)
Exception: Patients who have a Medication Administration Record (MAR) from
another facility and who are not going to be admitted. This list must be labeled,
reviewed with the patient, signed by the nurse and kept on the chart.
The BPMH must be complete on the Medication
Reconciliation and Physician Order form prior to the
physician writing admission orders.
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Date and
Time BPMH
done
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Patient
Label
List all
medications and
regular OTC’s
how the patient
is taking them at
home, including
name, dose,
frequency, route.
[MD, NP, RN,
LPN, RPN,
Pharmacist]
Draw a line,
sign and date
just below your
last entry.
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Form is to be
completed on
admission even if
patient has no
home meds by
checking the box
and signing the
form
Do not re-write
meds on ER
record or
admitting history
Check ALL sources of information
used to obtain BPMH. Keep copies of
lists and bubble pack labels etc. in the
chart for future reference by other
providers.
The source of the info gives credibility
to the list and assists physician
and/or pharmacist in further review
of medications. Prevents duplication
of effort by the next provider.
Use comments section to
Document any comments,
concerns or follow-up
required.
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Physicians:
Initial ‘continue’ box if
home medication dose, route
and frequency are to
continue as in BPMH.
If a home medication is
discontinued, initial
‘discontinue’ box and write
the reason for not ordering
this drug in the ‘Reason’
column.
(Remember that the form is being
used to communicate to other care
providers the changes in therapy).
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Physicians:
For any change in
home medication
dose, route or
frequency, initial
‘change’ column
and complete the
reason for the
change in the
‘Reason’ column.
Write the revised
home medication
order on the
regular physician
order form.
Sign and date
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(Draw a line from
last med ordered
to the physician
signature box to
prevent further
meds from being
added without
physician
approval).
Processing the
Orders
Check or initial in
the ‘Orders
Processed’ column.
Indicate when
orders copied and
sent to Pharmacy.
Sign and date
‘processed’ line.
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Late Entries;
If room, add new
information under
previous list; if no
room begin a new
form and draw a
line through the
orders. Sign and
date. Make a
comment in the
physicians orders
to have the new
information
addressed.
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Indicate the
number of pages
used
Self prescribed medications
These are medications that the patient
is taking to treat an illness (cold meds)
or as part of health promotion
(vitamins or supplements) that are not
part of the hospital formulary and will
not impact the current hospital stay or
management of an existing chronic
disease. They will not be continued in
hospital unless specifically requested
by the patient or physician.
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Betty Smith
Changes to home meds
written as new
medication orders
NKDA
Sept 27/07
1500
Admit to Dr. Black - pneumonia
CBC diff, Cr, lytes
DAT and AAT
O2 sats >91%
Daily INR and daily coumadin orders
Increase Lasix to 40 mg po daily
Levaquin 500 mg po daily
Prednisone 50 mg po daily x3 days
New medication
orders
Instruction to see Medication
Reconciliation and Physician’s
Orders form for home
medication orders
See Med Rec Form for orders
Dr. Black
Sept 28/07
Tylenol 650 mg po bid prn
TO Dr. Black/Pharmacist Jan
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Discrepancies from ‘Late
Entry’’ discussed with
physician and new orders
written.
Break Out Session
Betty Smith Case Study
15 minutes
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Break time!
5 minutes
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Who has the best med list?
Patient’s Actual Medication
Use
•
Patient Interview (What the
patient tells you)
•
Medication Lists?
Patient’s Medication
Regimen Prescribed
≠
•Medical Chart
•Medication Wallet cards
•Community Pharmacist
•Family MD
•Labels on Rx vials
What is the “truth”?
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Practical Tips for Obtaining the
Best Possible Medication History (BPMH)
1.
Interview the patient (and/or family member) regarding current
medications as taken at home. Use medical conditions as a
trigger to match medications. Ask about allergies and document
reactions on the Regional Allergy Form.
2.
Obtain home medication list or medication vials from patient.
3.
Don’t assume patient is taking according to label directions.
•
Ask if they or physician have changed the dose or stopped
any medication recently.
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Practical Tips for Obtaining the
Best Possible Medication History (BPMH)
4.
Ask if they take non-prescription medications on a regular basis
•
E.g. ASA, vitamins, herbals
5.
Ask if using any eye drops, creams, sprays, patches or injections.
E.g. Vitamin B12, Eligard®, Fragmin®
6.
Ask if physician has given them any samples.
7.
Inquire about multiple pharmacies. Teach about using a single
pharmacy.
8.
Verify accuracy of BPMH by validating with at least two sources
of information. (First source is always the patient/family)
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Information Sources
• Patient/family/care giver – best source if patient competent
• Prescription vials / Compliance packaging
• Medication List
• Community Pharmacy – obtain a patient medication profile
• Family Physician and/or specialist
• MAR from previous institution, admission
• netCARE PIN profile
• Medication Discharge Plan
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PIN Profile
Prescribing Physician and
Physician phone number
Date Rx
last filled
Number of
units filled
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Supply filled for
___# of days
Community Pharmacy
If days supply is 7, 14 or 28 days, it is
most likely that meds are dispensed in
compliance packaging.
Pharmacy Phone
Number
PIN Limitations
• DOES NOT include uninsured medications (i.e. paid by cash,
administered in an infusion clinic) OTC, herbals, vitamins if
medications not provided in a blister pack.
• DOES provide a starting point to ask the client what medication is
taken and how often.
• As of September 2007 all provincial pharmacies will be on line
improving the completeness of the information and will include
people under 65 years of age.
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Roles and Responsibilities
•
Admitting Clerk:
•
Register Patient
•
Attach PIN profile for all patients. They are requested to print
the history, not the PIN profile.
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Roles and Responsibilities in Emergency
•
ER Bedside Nurse:
•
Complete nursing admission assessment including Best Possible
Medication History (BPMH) prior to physician writing
admission orders.
•
Access required information sources.
•
Review lists with patient.
•
Flag form if unable to gather complete info at time
of assessment. Ask the next shift to complete.
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Roles and Responsibilities
•
ER Charge Nurse:
•
Ensure the Best Possible Medication History is complete prior
to physician writing admission medication orders.
•
Return to appropriate nurse to complete
•
Process orders from both the Medication Reconciliation form
and Physician Order Form.
•
Check the ‘orders processed’ column.
•
Sign and date on “Processed” line.
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Roles and Responsibilities in Emergency
•
ER Unit Clerk:
•
Process orders
•
Send form to pharmacy along with the Physician Order form
and Regional allergy form.
•
Sign and date “Orders to Pharmacy” and “Orders processed” if
you did them on med rec form.
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Roles and Responsibilities in Medicine/Surgery
•
Acute Care Charge RN:
•
Review orders from ER.
•
Ensure BPMH is completed (direct admits & transfers).
•
Reconcile orders with the BPMH. Bring discrepancies to the attention of the
physician.
•
In future, use of Med Rec form and current medication profile to determine
discharge Rx to be documented on the Medication Discharge Plan.
•
Bedside RN/LPN:
•
Complete BPMH on patients transferred from another acute care setting or
direct admits. Do not use the nursing database medication history. Use the Med
Rec form.
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Roles and Responsibilities
•Physician:
•
Verify home medication history with the patient.
•
Make a decision about each medication on the list indicating
that decision by initialing in the appropriate column (continue,
discontinue, change).
•
Document the reason for medications which are discontinued
or changed in the reason column.
•
Sign and date the form (making it acceptable as medication
orders).
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Roles and Responsibilities
•Pharmacists:
Secondary check of order accuracy
and completeness.
•
Review appropriateness of therapy.
•
Available for consult for patients with
complex medication regimes and for
patient teaching.
•
On transfer admissions, available for
consult when medications have been
changed and insufficient information
comes with the patient.
•
On discharge, available to assist with
complex medication regimes to improve
communication to community
pharmacists.
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Break Out Session
David Becker Case Study
15 minutes
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Future Directions
•
Discharge Reconciliation is a formal process of:
•
Comparing the BPMH from admission to the current medication
profile and making a conscious decision about every medication on
those two lists to determine what medications and doses the patient
should be sent home on.
•
Provides a check to determine if all appropriate prescriptions are
provided and to ensure that there is no duplication of therapy.
•
Physicians and/or nursing can use these two lists to reconcile
medications.
•
Bring discrepancies to the attention of the prescriber.
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Future Directions
•
Implementation occurring at all Suburban Rural Communities
facilities.
•
Regional expectation that implementation will be complete by
accreditation survey, October 2008.
•
Implementation at remaining Capital Health sites will begin
following accreditation with completion targeted before
accreditation 2011.
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In Conclusion
Strive for Patient Centered Care.
Systems Make it Possible but
YOU make the difference to the safety of
every individual.
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References
•
Fernandes, Olavo. (2006). Obtaining a Best Possible Medication History:
Sharing Practical Tips, Strategies and Solutions. retrieved from
www.saferhealthcarenow.ca on September 20, 2006.
•
Billman, Glen (2005). Medication Reconciliation power point presentation
retrieved from www.saferhealthcarenow.ca on September 20, 2006.
•
Northern Health Education session. Retrieved from
www.saferhealthcarenow.ca on September 20, 2006.
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