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Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

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Page 1: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Medication Reconciliation: Discharge Timeout

Casey Mashl, Pharm.DMitchell Chan, Pharm.D

PGY1 Residents

Administrator
Move the South County Health insgnia to the bottom
Page 2: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Overview• Medication reconciliation is a vital part of patient

care and safety• Maintains continuity of care• Ensures appropriate

continuation/discontinuation of medications at admission and discharge

• Discharge timeout process – Accountability– Continuity– Safety

Page 3: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

What is Med Rec?

• Medication reconciliation is a process to determine what Rxs, OTCs, herbals/supplements a patient is currently on

• Why do we need to do this?– Continue regimen while in the hospital– Determine if any medications are contributing to

the patient’s condition• Possibly increase/decrease or discontinue meds

Page 4: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents
Page 5: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

How is Med Rec Used?

• Physicians review med rec prior to entering admission orders– If med rec is entered incorrectly, inpatient

medications can be continued incorrectly and may lead to patient harm

– Inpatient and discharge medications are also chosen from the med rec

Administrator
Discuss the issue of continue form ambulatory and the changes we made based on placing a pharmacist at the beginning of the process to help fix these issues. ED pharmacist now added for new admits on second shift. Should also discuss the electronic discharge and how this has lead to user fatigue errors.Perhaps a slide on process?
Page 6: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Importance

• An accurate med rec allows for a safe transition of care both into the hospital and discharge to home

• When we know exactly what the patient taking at home, it allows for the highest level of medication optimization

Page 7: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents
Page 8: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Medication Reconciliation• Performed by– Pharmacist– Pharmacist Interns

• Multi-step process1.Review home medication list & External med history2.Perform patient interview3.Submit correct med rec into EMR4.Compare home meds with inpatient meds5.Contact ordering physician or practitioner

Page 9: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Medication Reconciliation

• IMAGE OF BAD MED REC

Page 10: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Discount Double Check

Page 11: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Discharge Timeout= Discharge Double Check

• Estimate of 2 in 5 patients in the hospital has discrepancies in their medication reconciliation that a pharmacist can correct and intervene1

• 56% reduction in chart discrepancies at discharge2

• Multi-step– Nurse-nurse, nurse-pharmacist check

• Admission• Discharge

1. Bishop MA, Cohen BA, Billings LK, Thomas EV. Reducing errors through discharge medication reconciliation by pharmacy services. Am J Health Syst Pharm. 2015;72(17 Suppl 2):S120-6.

2. Ruggiero J, Smith J, Copeland J, Boxer B. Discharge Time Out: An Innovative Nurse-Driven Protocol for Medication Reconciliation. Medsurg Nurs. 2015;24(3):165-72.

Page 12: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Discharge Timeout Form

Page 13: Medication Reconciliation: Discharge Timeout Casey Mashl, Pharm.D Mitchell Chan, Pharm.D PGY1 Residents

Conclusions

• Med rec is vital in maintaining continuity of care and patient safety

• Discharge time out process aims to reduce the number of chart discrepancies and negative medication-related patient outcomes

• South County Hospital Discharge Timeout update