Vicki Hannigan, M'D'

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Medication ReconciliationJCAHO Safety Goal 8

• Vicki Hannigan, M.D.
• Audrey Tio, M.D.
• Rikkita Hughes, CAC
• South Texas Healthcare Systems

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Purpose of Process

• To avoid errors of transcription, omission,
  duplication of therapy, drug-drug and
  drug-disease interaction (Poor communication of
  medical information at transition points is
  responsible for as many as 50 of all medication
  errors in the hospital and up to 20 of Adverse
  Drug Events)
• To improve the safety of the organizations
  medication management process and patient safety
• To use the list as a basis for required patient
  education on safe and effective use of medications

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Institute of Medicine Study 1997, released 1999

• 33.6 million admissions
• 2.9 - 3.7 occurrence of adverse events
• Annual Deaths
• 98,000 due to medical errors
• 43,385 due to motor vehicle accidents
• 42,297 due to breast cancer
• 16,516 due to AIDS

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Reconciling

• Is a process
• Is obtaining and documenting
• Is completing an accurate list of patient
  medications
• Is the involvement of patient and/or caregiver
• Includes prescribed medications by VA and non-VA
  providers, as well as over the counter and herbal
  remedies

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Completely Reconcile

• Compare and reach agreement
• Compare the home list (what the patient has
  been taking outside the VA) to what medications
  the organization is about to provide

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Communicating

• A procedure to ensure that a complete list of
  patients medications is communicated to the next
  provider of service when a patient is transferred
  or referred to another setting, service,
  practitioner, or level of care inside or outside
  the organization

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Definition of Medication

• Any prescription medications
• Sample medications
• Herbal remedies
• Vitamins
• Nutriceuticals (nutritional supplements, energy
  drinks, etc.)
• Over-the-counter drugs
• Vaccines
• Diagnostic and contrast agents (used on or
  administered to persons to diagnose, treat, or
  prevent disease or other abnormal conditions)
• Radioactive medications
• Respiratory Therapy treatments
• Parenteral nutrition
• Blood derivatives
• Intravenous solutions
• Any product designated by the Food Drug
  Administration as a drug

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Definition of Minimal Use Medications

• Topical fluoride in dentistry
• Local infiltration anesthesia for dental work or
  suturing lacerations
• Enteric barium for imaging studies
• The use of these medications typically occur as
  brief outpatient encounters, not involving other
  medication use, discharge prescription of
  medication, or any other changes in medication
  that the patient has been taking

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STVHCS Policy States

• That reconciliation should be done at every
  transition of care in which new medications are
  ordered or existing orders are rewritten

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Transition of Care

• Includes changes in setting, service,
  practitioner or level of care
• Applies across the continuum of care
• Occurs anytime a patient enters the health care
  organization (Emergency Department, Urgent Care,
  Ambulatory Clinics, Home Care Service, Inpatient,
  or other setting/service)

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This Safety Goal Applies

• If medications are to be used, the patients
  response to the treatment or service could be
  affected by medication that the patient has been
  taking
• To providers in all three STVHCS Divisions
  (includes Acute Inpatient/ Outpatient Care, Long
  Term/Home Care, and Behavioral Health) who are
  responsible to appropriately document and
  complete the Medication Reconciliation

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• Patients being admitted to an Acute Care setting
  will have their Medication Reconciliation
  documented and completed by the appropriate
  service Admission or History Physical Note
• - History Physical Note/Medicine
• - History Physical /Psychiatry
• - History Physical /Spinal Cord Injury
• - History Physical /Surgery

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Inpatients Being Discharged

• Providers will complete the Medication
  Reconciliation STX progress note
• Nursing and Pharmacy will not discharge patients
  until a Provider has completed the Medication
  Reconciliation STX progress note

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Patients Transferred

• When a patient is transferred from one level
  of care to another
• The Provider who write the new orders (the
  receiving physician) must complete the
  reconciliation process
• The medication orders written in CPRS must
  reflect the patients current medications
  (inpatients will not be taking non-VA meds or OTC
  meds)

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Outpatients

• For outpatient visits where there is a change in
  medication being made (new, deleted, change in
  dose or frequency) a new Medication
  Reconciliation note is required
• For outpatient visits with no changes made to
  medications, a new Medication Reconciliation note
  is not required

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Copies of Medication Reconciliation Notes

• Outpatients are provided copies of their current
  and updated Medication Reconciliation Note
  whenever a new one is created or at any other
  visit upon request
• Inpatients are provided copies of their
  Medication Reconciliation Note upon discharge
  from an Inpatient Acute Care or Resident Long
  Term Care status

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Communicating to Next Provider

• Within the VA, CPRS serves as the process to
  communicate to the next provider or setting the
  current medication list
• In all other cases (outside of the VA system)
  this information should be forwarded only if the
  patient consents to this communication of his/her
  personal health information

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What About Flu Shots, etc?

• Influenza vaccine and other vaccines are
  medications
• In the case of brief encounters where a single
  dose of a medication is administered and there is
  no change in patients continuing medication
  regimen, a new Medication Reconciliation note is
  not required but a Vaccine Information Sheet
  (VIS) will be provided to the patient prior to
  administering vaccine

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Monitoring for Compliance

• Service Chiefs will monitor and report
  compliance as directed by the Chief of Staff

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Helpful Hints

• Make all appropriate changes
  (adding/deleting/changing medication
  dose/frequency) in CPRS orders first
• Sign orders
• Refresh patient information under File option on
  patients chart
• Then start your Medication Reconciliation note

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Demonstration of Note
You will have one Template to choose from
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The Medication Reconciliation Note
Combines the Inpatient and Outpatient Options
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Inpatient/Outpatient Information
Both notes will have the same patient information
to help facilitate the note.
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The Inpatient/Discharge Note
will import the patients allergies and all
active and pending meds that the inpatient
provider has prescribed for the patient to take
after discharge. A comment box has been added
for additional instructions or additions.
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The Outpatient Note
This option will display the patient instructions
and information statements to help facilitate the
provider with finishing his/her note
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PATIENT DATA IMPORTED
The patients demographics, age, sex, weight and
SSN will be imported into the note just as before
along with the Allergies
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MEDICATION OBJECT
Just as the Inpatient/Discharge Note, the
Outpatient Note will have a medication object to
bring in the patients active medications that
have been already ordered prior to starting the
Medication Reconciliation Note.
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COMPLETED MEDICATION RECONCILIATION NOTE
This is how the Inpatient/Discharge Note appears
after it is populated into the patients chart.
It has the patient instructions and allergies
listed.
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COMPLETED NOTE CONTINUED
It continues with the patients list of active
medications including Non-VA medications
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COMPLETED OUTPATIENT NOTE
This is how the Outpatient Note appears when it
is populated into the patients chart. It too
includes the list of VA and Non-VA medications.
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Conclusion

• It is the responsibility as a patients
  Provider to complete the Medication
  Reconciliation note accurately for the safety of
  ALL patients