The Implementation of Medication Reconciliation in PAC Enhancing Patient Safety The Implementation of Medication Reconciliation in PAC Enhancing Patient Safety Safer Health Care Now !

Medication Reconciliation?Medication Reconciliation? Directions for CompletionDirections for Completion Frequently Asked Questions!Frequently Asked Questions!Medication History / Admission Order Form Medication History / Admission Order Form

Medication History / Admission Order Form Medication History / Admission Order Form

Directions for CompletionDirections for Completion

Implementing a Medication History/Admission Order Form

1. How in depth do we become involved to clarify accuracy of medication list when patients 1. How in depth do we become involved to clarify accuracy of medication list when patients are unsure of complete medication list taking? are unsure of complete medication list taking?

Determining the BPMH requires one to tap into all resources – patient / family interview, community Determining the BPMH requires one to tap into all resources – patient / family interview, community / hospital pharmacy, patient list or vials of medications upon initial admission, lists noted in previous / hospital pharmacy, patient list or vials of medications upon initial admission, lists noted in previous hospital chart. Note: the potential for adverse drug events occurs when we assume the list hospital chart. Note: the potential for adverse drug events occurs when we assume the list accompanying the patient is verified for accuracy. Consider any red flags that indicate patient may be accompanying the patient is verified for accuracy. Consider any red flags that indicate patient may be prescribed or not prescribed a medication in error. Thoroughly investigate as far as considered prescribed or not prescribed a medication in error. Thoroughly investigate as far as considered necessary to clarify accuracy of current medication list accompanying patient. Remember this step is necessary to clarify accuracy of current medication list accompanying patient. Remember this step is the most vital in preventing medication errors.the most vital in preventing medication errors.

Patient Medication Risk Assessment Tool (circle all applicable factors)

0 – 64 years

0

65 – 80 years

1

Age

>80 years

2

0 - 1

0

2 - 4

2

5 - 7

3

Number of Medications

Prior to Admission

8 or more

6

Antiseizure

3

Anticoagulant

3

More than two cardiovascular medications.

5

High Risk Medications

Prior to Admission

Diabetic Medications (oral+/- insulin)

2

Is the patient confused regarding his/her medication regime?

Automatic Referral to Pharmacy

Has the patient been hospitalized for medication management concern within the last year?

Automatic Referral to Pharmacy

Total Score

Examples of medications for each medication category: Antiseizure: e.g. carbamazepine, phenytoin, valproic acid & divalproex sodium. Anticoagulants: e.g. warafin, low molecular weight heparin (e.g. tinzaparin, dalteparin, enoxaparin), heparin. Not ASA. Cardiovascular Medications: e.g. blood pressure meds, cholesterol meds, digoxin, amiodarone, daily ASA, clopidogrel, diuretics. Do not count anticoagulants as a cardiovascular medication. If total score is > or = to 10, referral to Pharmacist is recommended.

NOTE: Fax to Pharmacy on day of admission.

PAC Nurses: Ensure all sources required to verify the Best Possible Medication History (BPMH) are indicated upon admission.

PAC Nurses: Indicate any illnesses patient has.

Physician: post-op checks appropriate boxes indicating if pre-admission medications are for Continue, Change, Hold or Discontinue. Also, indicate reason for Hold, Change or Discontinue. Note: New medications that may be ordered post op are indicated as usual on the pink Physician Order Sheet.

If Inpatient RN is in situation of receiving orders by phone the RN checks the appropriate boxes as ordered and signs here as per telephone / verbal order. Later, to be cosigned by physician as per usual policy.

Staff member verifying the medication for the BPMH initials appropriate box for each medication verified.

Physician: signs here for approval of the boxes that were checked with each medication

PAC Nurses: When the BPMH is collected sign indicating so.

PAC Nurses: If BPMH collected by more than one RN indicate both signatures.

PAC Nurses: List all medications patient taking at home, including OTC and Herbals. Ensure list is as accurate as possible before adding to list. This forms the BPMH-Best Possible Medication

History. Thorough medication history taking practices are vital in this step. Please review interviewing techniques (listed on this

poster) for important steps to consider. Remember this list will form basis for Admission Orders post-op, after verified with physician .

Pre-op Nurses or Inpatient Nurses: If additional regular pre admission / transfer medications are identified after initial BPMH was collected (ie. upon day of admission for surgery or later) indicate here and sign as addition to BPMH.

PAC Nurses: After collecting BPMH list indicate Risk Score after completing Risk Tool on back of this form (Tool shown here)

Inpatient RN: Following completion of orders the front and back of this form (medication history/orders and completed Risk Tool) is faxed to Pharmacy.

2. Are all medications – OTC, herbal- listed when collecting the Best Possible Medication 2. Are all medications – OTC, herbal- listed when collecting the Best Possible Medication (BPMH)? (BPMH)?

List all prescribed, OTC and herbal medications determined to be taken by the patient or physician List all prescribed, OTC and herbal medications determined to be taken by the patient or physician recommended medications? Once listed the ordering physician decides if the medications listed then recommended medications? Once listed the ordering physician decides if the medications listed then should be continued, discontinued, etc upon admission.should be continued, discontinued, etc upon admission.

3. Sometimes patients after initial day of admission report they take additional medications 3. Sometimes patients after initial day of admission report they take additional medications that they forgot to indicate at the time the medication history was collected. Where are these that they forgot to indicate at the time the medication history was collected. Where are these medications then listed and ordered? medications then listed and ordered?

Such medications are listed in the Such medications are listed in the Additional MedicationAdditional Medication section so that all pre-admission medications section so that all pre-admission medications are listed in one area. In addition, the physicians intention to continue, discontinue, hold, change etc. are listed in one area. In addition, the physicians intention to continue, discontinue, hold, change etc. should still be checked in the appropriate adjacent boxes by the nurse after discussion with the should still be checked in the appropriate adjacent boxes by the nurse after discussion with the physician. However, the physician order for these additional pre-admission medications that are now physician. However, the physician order for these additional pre-admission medications that are now noted at a later date is to be indicated on the pink Physician Order sheet. This is because usual noted at a later date is to be indicated on the pink Physician Order sheet. This is because usual processes do not trigger a nurse to backtrack and check for orders that may have been documented processes do not trigger a nurse to backtrack and check for orders that may have been documented on a form initiated days before.on a form initiated days before.

4. How can I be sure I have a BPMH? 4. How can I be sure I have a BPMH?

BPMH means obtaining the best possible medication list possible. Ensure you practice good BPMH means obtaining the best possible medication list possible. Ensure you practice good medication history taking techniques. Refer to medication history taking techniques. Refer to Tips For Medication History TakingTips For Medication History Taking indicated below. indicated below. Ensure you consider all possible resources (as indicated on Medication History / Admission Order Ensure you consider all possible resources (as indicated on Medication History / Admission Order Form) for information that can verify a current accurate medication list.Form) for information that can verify a current accurate medication list.

Tips For Medication History TakingTips For Medication History Taking

• A process in which medications are compared at interfaces of care:

Admission Transfer Discharge• Discrepancies are identified and reconciled with

physician• Intervention minimizes patient harm from unintended

discrepancies ISMP Canada 2005

Questions to Ask for a Medication

History 1. Ask about all medications: ∙ Prescription ∙ Over-the-counter (non-prescription) ∙ Anything from a herbalist or health food store ∙ Vitamins or supplements ∙ Traditional remedies 2. Include: ∙ Name ∙ Dosage form ∙ Dose ∙ Schedule ∙ Last dose taken Note: be specific about prn medication 3. Ask about recently started medications or dosage changes

Tips for Performing a Medication History

∙ Balance open-ended questions with yes

/ no questions ∙ Ask nonbiased questions ∙ Don’t ask leading questions ∙ Vague responses may indicate non-adherence ∙ Avoid medical jargon ∙ Encourage questions from patient ∙ Educate patient to bring medications from home ∙ Educate resident to carry a list of current medications ∙ Prompt regarding non-pill dosage forms such as patches, creams, eye drops, inhalers, sprays, samples, shots ∙ Do not assume instructions on prescription vial labels are current. If the medication vials are available, review each medication individually with the patient. Ask them how they take each medication. ∙ Ensure the vial contains the medication specified on the label. ∙ Prompt regarding prn medication ∙ Allergies: ask about symptoms ∙ Use multiple sources of information:

- Medication lists / vials - Family - Community Pharmacy - Family physician

Other Questions for Medication History Interviews

1. Did a doctor change the dose or stop any of your medications recently? 2. Have you changed the dose or stopped any of your medications recently? 3. Have any of the medications been causing side effects?

Note: PAC Nurses do not fax this form to pharmacy on the day the medication history and risk score is completed in PAC Clinic. This is done post-op by inpatient RN who is receiving the patient.

Western Regional Integrated Health Authority *For Western Preadmission Clinics and WMH Surgical Inpatients Use Only*

MEDICATION HISTORY ADMISSION MEDICATION ORDERS

**Keep this form with the Physician Orders**

Site:

________(Indicate Unit) Sur gical InpatientsWMH ________(Indicate Site) Preadmission Clinic Patient Label/Addressograph

This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for pre-admission medications. New medication prescribed on admission should be written on the physician’s order sheet.

Source of Medication Information (Check ALL that apply) Review of patient/resident medication list Review of medication vials Review previous hospital records Family Physician list Patient/resident recall Family/caregiver recall

MA MAR from another facility Other:__________________ Community pharmacy list Pharmacy Name:______________________

Diagnosis: (check all that apply) □ IHD □ PVD □ Renal □ R.Arthritis □ Epilepsy □ AFiB □ CVA Failure □ O.Arthritis □ Anxiety □ CHF □ HTN □ COPD □ NIDDM □ Depression □ Dyslipidemia □ Multiple Sclerosis □ IDDM □ Other:

Weight: kg Allergies: Height: cm

Medication History: BPMH (Best Possible Medication History)

Physician Admission Orders: To complete upon admission

Medication Name & Strength (List all prescriptions and regularly taken OTC & PRN medications prior to admission).

Dos

e

Rou

te

Dos

ing

Inte

rval

Verif

ied/

Initi

al

Cont

inue

Cha

nge

Hol

d

Disc

ontin

ue

Reason for Change/Hold/Discontinuation

BPMH obtained by: ________ Date/Time: __________ BPMH obtained by: _________ Date/Time: __________

Has the BPMH collected in PAC Changed? Yes (Make Changes)No Prescribing Physician: Date/Time:

Additional Medications Identified After Medication History Taken ( Please Fax Additions to Pharmacy)

Note: Any additions to Preadmission medication list/s received after list above is verified Requires the physician orders written on routine Physician Orders (pink form). BPMH obtained by: ________ Date/Time: __________ BPMH obtained by: ________ Date/Time: __________

NOTE: For all additional preadmission medications received after the BPMH has been completed still indicate intent regarding Continue, Discontinue, Change, Hold.

Please complete additional forms if additional space for medication list is needed. Risk Score: (see tool form # ) Pharmacy Consult Recommended No Yes Reason for Referral: NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not. Disposition of Patient’s Medication on Admission : Locked up in nursing unit Brought to hospital. Sent home with: Not brought to hospital Original Copy – On Chart Copy – to Pharmacy Fax to Pharmacy: Pages(s) of . Form #

Note: This completed form becomes the admission medication history list. Therefore, to reduce duplication and reduce potential for error with multiple lists any other areas where medication history list have been usually written (ie. admission history or nursing kardex) should indicate for pre-admission medications “See Medication History / Admission Orders List”

Pre op Nurse: verifies that nothing has changed since medication list taken in PAC. If Yes, note in additional medication section.

Pharmacy: If Risk Score indicates, Pharmacy will also assess patients BPMH and indicate any additions or revisions in the Additional Medication section that is related to accuracy of the BPMH. As well, will follow up by communicating to unit nursing staff and / or physician of any recommendations related to the medication regime. The referral process may take up to 48-72 hrs for pharmacy to complete the patient assessment.