Medication Reconciliation Process Overview

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Medication Reconciliation Process Overview
Admission Phase Ia Develop Medication
List Collect, Verify Clarify Meds
Admission Phase Ib Admit Reconciliation
How? 1. Compare list to new med orders. Note
any -Duplications -Omissions -Changes
-Formulary substitutions -Holds or DCs
Who? RN Pharmacist MD/provider
How? Use sources of info such as -patient -family
-pt. med list -PCP -Transfer form -Pharmacies
Who? RN Pharmacist Pharmacy Tech. Surgical
RN Preadmit staff MD/Provider
Physician
2. Finalize List (signature)
PHASES
Phase II Transfers and Updates Maintain
Update Medication List
ADMISSION
Phase V Maintain Update List (Community)
TRANSFER
How? Review current med list on each change in
care for -Duplications-Omissions -Changes
-Formulary substitutions -Holds or DCs
Who? RN Pharmacist MD/provider Unit Secretary
How? Provider patient medication list with
directions to take to all appointments and
providers of care.
DISCHARGE
POST-DISCHARGE
Phase IV Communicate/Continuity of Care
Phase III Discharge Reconciliation
How? Deliver the discharge med recon list to the
patient the next providers of care,
including -Physicians -Outpt treatment
providers -Pharmacies -Caregivers Family
Who? RN Pharmacist/ Pharmacy MD/provide Dsch
Planner Case Manager Social Worker
How? 1. Compare preadmit med list to meds at
time of discharge Note any duplications,
omissions, changes, formulary substitutions,
holds or DCs. Explain changes and
assure continuity.
Who? RN Pharmacist MD/provider
2. Finalize List (signature)
Physician
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Med Recon Process Mapping
Admission
Direct Floor
Direct ICU
ER
OR
How will the preadmit medication info be recorded
at your institution? Use your Home Medication
Reconciliation orders to record the home
medications. Where would this info be located?
Who would have access? How will you know when the
list is complete?
Task 1 Develop a Preadmission Med
List Collect, Verify, Clarify
Read Day 1 of case study and identify common
sources of medication info to complete med
list. 1. 2. 3. 4. 5. 6.
Read Day 2 of case study. Determine a timeframe
for when the med info can or should collected?
How can you assure follow-up on incomplete
info? At what point can you finalize the list?
Who would or could collect this info at your
institution? Who might verify of clarify
incomplete or suspect info? Considerations
include -What is the normal process of
care? -Who are most qualified staff? -Resource
limitations/Who can actually provide this
service? 1. 2. 3. 4. 5.
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Med Recon Process Mapping
Admission
Task 2 Reconciliation of preadmission meds to
new orders
Compare preadmit med list to new med orders.
Look for any -Duplications -Omissions
-Changes -Formulary substitutions -Holds or
DCs
Who would or could perform this reconciliation
at your institution? How will
reconciliation by documented or demonstrated at
your institution? (ie, When you look at a chart
how will you know reconciliation was
accomplished or how will you identify patients
in need of reconciliation?)
Using the home medication form, perform
reconciliation and determine which meds you
wish to continue. (ie, Indicate Yes or NO for
continue Meds during hospitalization.) Sign and
date the form.
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Med Recon Process Mapping
Transfers and Updates
Task 3 Reconcile or compare new orders to
preadmit med list.
Using the provided medication administration
record (MAR) create a list of the current meds by
adding the home medications you decided to
continue.
Review current med list on each
for -Duplications-Omissions -Changes
-Formulary substitutions -Holds or DCs Who
would be responsible for this review at
your institution? How would you indicate
that reconciliation occurred?
Read Day 3 of the case study. Add the newly
ordered medications to the MAR.
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Med Recon Process Mapping
Discharge
Task 5 Communicate info to next providers of
service
Task 4 Perform discharge reconciliation
Read Day 4 of the case study. Compare home med
list to meds at time of discharge. Note any
duplications, omissions, changes, formulary
substitutions, holds or DCs.
Determine a process that assures delivery of
the discharge med recon list and other critical
health info to the patient the next providers
of care ( including physicians, outpt treatment
providers, pharmacies, caregivers family)
Who would complete this? How would this
process be standardized? What information from
this particular case would be important to
communicate?
Complete the discharge (new home) medication
form filling out the appropriate info with the
medications you choose to continue.
Who will perform this reconciliation/review at
your institution? How will they have access
to the current med list and the preadmit/home
med list?
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CASE STUDY FOR MED RECON ADMISSION Day 1 CF is
a 68yo male admitted directly to the medical
floor of your hospital (during evening shift)
with a diagnosis of severe LLL pneumonia. He
does not have a current a list of medications and
dosages. His wife says that he has a history of a
heart rhythm problem. He knows that he takes a
water pill and a heart pill. The Hospitalist
writes the admission orders and requests a
cardiology consult. The admission medication
orders include 1. Levofloxacin 500mg IV Q 24hrs.
2. Digoxin 0.125mg PO daily 3. Acetaminophen
650mg PO q4h prn Temp gt 101.5 4. IV fluids of D5
½ NS at 80ml/hr ADMISSION Day 2 CFs family
members arrive the next day with a bag of his
medications including vitamins and an
alternative medication. The medications CF was
taking at home appear to be 1. Aspirin 81mg PO
daily 2. Furosemide 40 mg PO daily 3. Atenolol
50mg PO daily 4. KCl 40mEq PO daily 5. Loratadine
10mg PO daily 6. Multivitamin 1 tablet daily 7.
Co-Q10 8. Ibuprofen 400mg TID PRN
pain/stiffness UPDATES AND TRANSFERS Day 3
After several days CFs pneumonia is improved.
However, he is seen by a cardiologist, has an
echocardiogram performed, and is diagnosed with
heart faliure with an ejection fraction (EF) of
30. The cardiologist writes new orders for 1.
Metroprolol XL 50mg PO daily... and 2.
Lisinopril 5mg PO daily. CF also receives
pneumococcal and influenza vaccinations on Day
3. DISCHARGE Day 4 CF is ready for discharge
and is scheduled to receive follow-up and
treatment from the medical centers heart failure
clinic. The Hospitalist writes the discharge
medications 1. Aspirin 81mg PO daily 30 2.
Lisinopril 5 mg PO BID 60 3. Metoprolol XL 50mg
PO daily 30 4. Furosemide 40mg PO daily 30 5.
KCl 20 MEQ PO 2 tablets daily 60 6. Levofloxacin
500mg PO daily 6