Presentation to introduce MedRec to LTC nursing staff

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Medication Reconciliation Opportunity to
Improve Resident Safety
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Overview and Objectives

• Following this session you will gain an
  understanding of how
• To conduct a medication reconciliation on all
  new admissions and readmissions to long term
  care,
• To obtain a best possible medication history on
  each new resident
• Medication Reconciliation impacts on resident
  safety

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Transitions in Care
Acute Care
Ambulatory Care
Home Care
Long Term Care
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Impact

• The potential for medication errors and resident
  harm exists if medication histories are
  inaccurate and/or incomplete and are subsequently
  used to generate the resident's medication
  orders
• Lack of knowledge of residents medications at
  transition points (admission, transfer,
  discharge) is believed to be a key source of
  adverse events
• Massachusetts Coalition for the Prevention of
  Medical Errors

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Medication Reconciliation in Long Term Care
Safer Health Care Now Video
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What is Medication Reconciliation?

• Process of collecting and documenting complete
  medication and allergy histories from the
  resident and/or family.
• Process of comparing and deciding which
  medications should be continued, held, or
  discontinued on admission and at discharge.
• Includes communication between health care
  providers.
• Includes a commitment to review all medications
  at time of admission, transfers, and/or
  discharge.
• Intended to minimize potential harm from
  unintended discrepancies
• Timely process but well worth the time spent
  leads to better resident outcomes.

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What is Medication Reconciliation?

• Occurs at transitions and interfaces of care
• Indentifying discrepancies
• Resolving discrepancies
• Preventing adverse drug events by
• Eliminating undocumented intentional
  discrepancies
• Eliminating all unintentional discrepancies

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What is the Goal of Medication Reconciliation

• Eliminate unintentional discrepancies
• Decrease medication related adverse events
• Improve client safety

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Why Perform Medication Reconciliation?

• Rate of medication errors in a 6 month period
  decreased by 70 after implementation of a
  medication reconciliation process at all phases
  of hospitalization - Rozich J.D. Resar R.
  JCOM. 2001 8 27-34
• Pharmacist participation on medical rounds and
  reconciliation and verification of patient
  medication profiles at interfaces of care greatly
  reduced medication errors - Scarsi, K et al. Am
  J Health-Syst Pharm. 2002 59 2089-92
• One study found 94 of the patients had orders
  changed after an ICU stay. By reconciling all
  pre-hospital, ICU and discharge medication
  orders, nearly all medication errors in discharge
  prescribing were avoided - Provonost P, et al.
  Journal of Critical Care. 2003 18201-205.

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Challenges

• Resident and/or advocates ability to recall
  medications, doses and/or frequency of use
• Stress of transitioning through the healthcare
  system
• Health Literacy
• Language barriers cultural beliefs
• Relationship with the healthcare clinician who is
  obtaining the history

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Challenges

• Interviewers skill level
• Time constraints
• Accuracy and completeness of medication histories
  obtained from other resources
• Accessibility of residents medication list
  during night/weekend hours

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Sources of Information from Another LTCF or
Hospital

• Previous 24-hours MAR
• Medication Profile
• Resident Assessment instrument (RAI) standard
  screening/assessment tool LTC
• Pre-LTC/Hospital Medications

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Four Steps1. Obtaining the Best Possible
Medication History (BPMH)2. Identifying
discrepancies3. Reconciling discrepancies4. Sp
reading processes to other transitions of care
Steps to Conducting a Medication Reconciliation
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Step 1. Collect an Accurate Allergy and
Medication History

• Collect an Accurate Allergy and Medication
  History
• Taking a complete allergy and medication history
  is an essential step toward ensuring resident
  safety.
• The risk of preventable adverse medication events
  can be significantly decreased by knowing the
  complete medical history.

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What is Defined as a Medication?

• Blood derivatives
• Intravenous solutions (plain or with additives)
• Any product designated as a drug
• Diagnostic and contrast agents

• Prescription medications
• Implanted pumps,
• Narcotics, etc
• Sample medications
• Vitamins
• Nutriceuticals
• Over-the-counter
• Radioactive medications
• Respiratory-related medications
• Parenteral nutrition

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Overlooked and Easy to Forget Medications

• Implanted pumps
• Eye drops
• Nasal sprays
• Vitamins
• Herbals
• Homeopathic remedies
• Creams

• Narcotic Patches
• Over-The-Counter
• Samples
• Dental medications
• Inhalers
• Dietary supplements

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Interviewing the Resident and / or family member

• Ask about medications
• Use open-ended questions.
• Use nonbiased questions.
• Pursue unclear answers.
• Ask simple questions.
• Review medications brought to the home on
  admission.
• Prompt the resident/family for other medications.
• Discuss allergies.
• Investigate residents medication compliance.
•  

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Seeking Clarification

• Obtain a detailed description of the medication
  from the resident/family .
• Talk to any family members present or contact
  someone
• Ask the pharmacist to call the residents
  pharmacy.
• Contact the residents physician(s).
• Obtain previous medical records and compare this
  with the admission orders.

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Interviewing Strategies

• Introduce yourself
• Use open-ended questions
• Pursue unclear information until it is clarified
• Review any med wallet cards carrying by the
  resident or any list of meds brought with them.

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Interviewing Strategies

• Dont accept med lists without verifying the
  information with the resident, and/or caregiver
• Link medications to conditions
• Assess residents compliance by asking questions
  such as
• How do you take your medications?
• Are there any medications that you have stopped
  taking?
• Why did you stop them?

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Additional Questions to Ask

• What does the tablet you are taking look like?
• What medication do you take for your heart
  problem?
• Are there medications that you take only
  sometimesor when you need them? How often do you
  take it?
• When was the last time you took it?
• Does your doctor give you any sample medications
  totake?

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Sample Medication History Questions

• Lets look at yesterday. Starting from when you
  woke, what was the first medication you took?
• How many times a day did you take it?
• What are you taking it for?
• What other medications did you take?

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What Information is Necessary about
theMedications?

• Medication Name
• Dose (mg, tab, etc.)
• Route of Administration
• Frequency (How often?)
• What time of the day?
• When did you most recently take the medication -
  (date/time)
• Reasons for the medications

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Sample Allergy History Questions

• What medication allergies or adverse drug
  reactions do you have?
• Educate the resident/family about the difference
• True Allergies cause reactions such as a rash,
  bronchospasm, itching, etc.
• Adverse Drug Reactions are the patients response
  to the drug such as nausea, dry mouth, etc.
• What was the medication?
• When did this happen?
• What other types of allergies do you have food,
  environmental?

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Step 2. Identifying Discrepancies

• Cross check the admission orders against
• Previous MAR from discharging facility
  specifically most recent medications given
• CCAC MDS assessment forms checking through all
  pages for any handwritten notes
• Any previous orders/MARS, if a readmission
• List of medications from resident/family

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Identifying Discrepancies

• Refer to the arrival list when writing medication
  orders for admission, transfer, and discharge.
• Compare the arrival list with every medication
  ordered at admission or discharge and look for
  discrepancies
• Address ALL discrepancies with the physician

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Step 3. Reconciling Discrepancies

• Share the List
• Upon admission/readmission, inform physician and
  pharmacist of any discrepancies
• Document any discrepancy in the admission
  progress notes
• When transferring, or discharging the resident to
  an outside facility, remember to provide
• A copy of the most recent MAR.
• A copy of the transfer record.
• Discuss the discharge instructions with the
  resident and/or caregiver.

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Step 4 Process Changes for Medication
Reconciliation

• Establish the expectation that residents come
  with all their medications upon admission.
• Improve access to complete medication lists at
  admission, readmission, transfer and discharge.

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Types of Medication Reconciliation Errors

• Improper dose/quantity
• Omission error
• Prescribing error
• Wrong drug
• Wrong time

• Extra dose
• Wrong resident
• Mislabeling
• Wrong administration technique
• Wrong dosage form
• Medmarx reporting program

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When do you Conduct a Medication Reconciliation?
At all transfer points of care
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Questions?