2. Medication Reconciliation
Education
Purpose: We can improve patient safety and care
outcomes by performing medication reconciliation
Everyone plays a role in Medication Reconciliation
Our medication reconciliation policy has been
simplified
Audits have shown that Medication Reconciliation
done by nurses are sometimes incomplete
This is your education about the new policy changes
3. Medication Reconciliation
Our policy is organized in 3 ways:
1. Patient Status
• ED vs. Inpatient/Observation
2. The action occurring with the patient
a) Admission
b) Transfer
c) Discharge
3. Role of person engaged in Med Reconciliation
a) Nursing responsibilities
b) Pharmacy responsibilities
c) Prescriber responsibilities
Note: For this education, we are focused on Nursing responsibilities only
5. Medication Reconciliation
Exceptions to completing the regular process:
ED: review names only
Cardiac Cath/EP lab: med report from field
Interventional radiology: provide pharmacy list of
meds, allergies and contrast medication orders
Daycare patients for procedures (with no med adjustment):
med names and allergies
Peds sedation: Med names and allergies
Dialysis – dialysis meds are not included on home
med list
6. Medication Reconciliation
ED (preadmission)
Review names of meds only
Record dates and times of last doses for
antibiotics and b-blockers
Record any other med information related
to care in the ED in the text box for last dose
If there is a med that has been completed
you may remove by using the red X
In the text box for Last dose:
Type“Y” if pt is taking the medications
Type “N” if pt is not taking the medications
When review is complete fill in status box
Mark as reviewed
7. Beta-blocker or Antibiotic here Date and time here
Select one of these 3 “y” or “n” in this
options text box
8. Medication Reconciliation
Admission – Nurse responsibilities
Goal: Obtain medication history to create an accurate
home med list
Exceptions for starting this process…
1. Certain patient populations:
SNF and CBRF patients- give a copy of MAR to pharmacy
SPC – pharmacy interviews surgicals and medical EMAs, RN interviews the
other medical patients
ER only verified names of meds, admitting RN needs to complete
2. Pharmacy has already completed the med history or
reconciliation (see next slide)
9. If pharmacy has chosen a
status before you begin…
call the pharmacist prior to
changing the list or the
status box
10. Reviewing Medications
Information to include with each med:
Name Metoprolol Multivitamin
Dose 25 mg One
Dose form Tablet Tablet
Route By mouth By mouth
Frequency Daily daily
Date/time 2/28/13 0800 2/28/13 am
of last dose - am/pm is ok most of the time
Beta blockers, Antibiotics need specific time
Ask about OTCs, herbals, eye drops, nasal sprays
etc
11. Adding Medications
Add the missing medication, include the same elements as in the
review and document date and time of last dose
Add date and time of last dose
Add all
medication
information
12. Removing Medications
Remove meds that the patient is appropriately not
taking by using the red X and selecting “remove
from PTA list”
examples: completed antibiotics
completed surgical prep
MD instructed pt to d/c use
Duplicate entries of the same med
13. Changing Medications
ifpatient is taking med differently
than listed but according to MD
instruction
remove med entry using red X
add med as above
14. Unclear Entries
If it is unclear if the medication should be removed from
the list or changed, just type the information into the
last dose field for the pharmacist to review.
When might this happen?
Non-compliant patient
Patient changed dose or frequency without MD
knowledge
Patient misunderstood directions and has been taking
incorrectly
Pt stopped med for financial reasons
Patient can only provide a portion of the information
15. Please use last dose field for
communication…not the paper icon
Writing in the paper icon stays
in the chart forever so just
pretend it isn’t even there!
Happy
Pharmacist
Unhappy
Pharmacist
17. Medication Reconciliation
Transfer of patient – Nurse responsibilities
Release orders at the time of pt physically transferring
to the new unit
If pt unable to be physically transferred, release and
act on the orders – the orders are considered a level
of care change regardless of physical location
18. Medication Reconciliation
Discharge – Nurse responsibilities
Review the orders and check the status of
d/c orders in shopping cart
Provide patient necessary discharge
documentation, medication education
and d/c instructions
d/c to another provider: print facility
transfer order report (2 copies – one for
facility and one for SMH chart)
Admission as inpatientTransfer in and out of ICU or ORDischarge: home or to other facility
RN’s job is to take history from the patient/caregiverto create an accurate home med listAfter history has been taken, pharmacy will see what has been ordered and then do the RECONCILIATON between home meds and ordered meds to make sure our patients are getting the correct medications!!Exceptions for starting this process…SNF/CBRF patients: provide MAR to pharmacy by making a copy of original for themEMA: early morning admissions and surgicals interviewed by pharmacist in SPC but other medical patients should be done by RNCPU: nurse or physicianER: minimal expectation is verifying NAMES ONLY- additional info may be obtained and added If pharmacy has started do not change anything – just call pharmacy. We will see in later screen shots how to tell if pharmacy has started.
Here is where we talk about if a pharmacist has already begun…if you get to med rec and pharmacy has already begun, the status menu will be filled out already with an RPh statusIf one of the highlighted choices is selected, please…do not change anything in the list…and do not change the status – call pharmacy with any changesThis alters our reporting for med reconciliation for meaningful use numbers!!
Examples:Name =metoprololDose= 25 mg, one etc.Dose form = tablet, liquid etc.Route = by mouthFrequency = dailyDate/time of last dose = am/pm or actual timeAnother example…multivitaminMultivitamin needs to have “one” as dose…for an incomplete order complete order it would read:Multivitamin one tablet by mouth daily
Still need to add dates and times of last doses
This makes everyones job easier, placing it in the text box it is kept with this admission instead of forever.
click#1: For each med:Review name, dose, route, frequency for accuracy of what pt is doing at homeclick#2: also for each med: add date and time of last dose and any other information to share with pharmacy.click*** here is where you would use the red X to delete medications that don’t need to be on the list. If you need to delete a medication and then re-add it as necessary to make this list correct.When you have finished the list…click#3: pick your status…click inpatient RNs pick from: RN: unable to obtain, RN:incomplete or RN:completeclick ER RNs pick from: ED: unable to obtain, ED:incomplete or ED:completeclick#4 add a reviewer note… clicking on the “add note” link brings up a pop up boxclickuse the smart phraseclick#5 click on mark as reviewed – this is how you get credit for all of the work you just did and how it saves the changes you made in the history section.clickwhen you do that, your name will appear as the person who last reviewed the information. clickHistory – able to pull up history of who did what with the med rec…used mostly by pharmacy and QI auditors
If pt is OOU and held in ICU because there are no beds and then declines, must then med rec again…if again made ICU patient.
Show facility transfer order report:Patient summary – report (wrench)- facility
