Medication Reconciliation 2013

Medication Reconciliation

2 What is medication reconciliation?

  Active decision about medication requirements during a transition of care after reviewing home medications for possible drug-drug interactions, drug duplications, dosing errors, or omissions[1]    Adding a new medication Stopping an existing medication Changing an existing medication (dose and/or frequency) Medication reconciliation should be considered at major transitions of patient care  Ambulatory facility/ED visit    Admission to hospital/other facility Transfer to a different level of care in same facility Discharge from hospital/other facility

Medication Reconciliation Facts

3 Why is medication reconciliation important?

    2,022 reports of medication reconciliation errors from September 2004 to July 2005 reported to US Pharmacopeia (USP)[2]  22% occur at admission   66% occur at transition in level of care 12% occur at discharge 1.5 million preventable adverse drug events (ADEs) occur annually as a result of medication errors  $3 billion per year cost associated with preventable ADEs 50% of all hospital-related medication errors and 20% of all ADEs result from poor communication at the transitions of care[3,4] ADEs result in 2.5% of ED visits for all unintentional injuries and 6.7% of those leading to hospitalization[5]

Medication Reconciliation

4 Why is medication reconciliation required?

   Quality of care:  reduce adverse events  lower cost Professionalism:  prevent errors in care Regulatory:  The Joint Commission requirement

UCI Med Reconciliation Process

5  Obtain an accurate home medication list at start of patient encounter by     Physician/NP/PA Nurse Pharmacist MA  Use various tools in Quest for viewing/updating home medication list and inpatient medication list for reconciliation at major transitions of care

UCI Med Reconciliation Process

6 What features does each tool have for medication list?

OMR Rx Writer OR Manager Clinical Summary Tab Orders Tab

(ORM) Med Reconciliation View Pharmacy View View home medications Update home medications View home medications View home medications Update home medications Update home medications View home medications View inpatient medications Rx new home medications Rx new home medications Order inpatient medications View inpatient medications Manage inpatient medications

Order icon

Order inpatient medications

UCI Med Reconciliation Process

7 Select your primary role:  Adult patient care  Neonatal patient care

Admission to hospital Everyone has a role

UCI Process - Adult Patient Care

8 Obtain/document medication Hx Physician/NP/PA gets medication Hx from patient and Quest tools and documents medication list in H&P and/or OMR Nurse gets medication Hx from patient, H&P, and Quest tools and documents medication list in OMR with status of review Reconcile home/inpatient medication Physician/NP/PA reconciles home medications with inpatient orders in Order Reconciliation Manager (ORM) within 24 h of admission

Documenting Home Medications

9 Updating the home medication list in Quest tools maintains a consistent list of home medications that can be referenced in the Clinical Summary Medication Reconciliation view Status of home medication list is indicated

+

Add home medication

New Quest Tools - O

M

R

10 Home Med Review status Update status of home medication list: taking, not taking, unknown, or incomplete Edit Pharmacy info Mark as reviewed

?

Needs follow-up for incomplete info No longer taking Edit medication dose or frequency

New Quest Tools - O

R

M

11 Select here for admission reconciliation.

Status of medication reconciliation displays

New Quest Tools - O

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M

=Home medication list (in OMR) not done =Home medication list (in OMR) incomplete =Home medication list (in OMR) complete 12 If home medication list needs editing, it can be done by using + Enter function, launching OMR, or editing each drug individually Floating menu arrow Only works if home medication list was complete and all medications are reconciled; otherwise, it will save as “incomplete”

Floating menu arrow Convert to inpatient order=

Admission Reconciliation [Expanded View]

13 Change dose/frequency or alternative drug Stop/hold on admission= Reconciliation options for home medications appear after hovering over floating menu arrow (see previous slide)

Admission Reconciliation

14 If there is an existing inpatient order, it will match up with closest home medication for reconciliation Home Medications Inpatient Medications

Admission Reconciliation

15 All home medications reconciled Home Medications Inpatient Medications Held on admission Patient was no longer taking this drug, so it becomes crossed out Continued as inpatient order

Admission Reconciliation

16 Enter additional admission medications

Discharge Reconciliation

17

Discharge Reconciliation

18 Use Discharge Note to launch discharge reconciliation (ORM)

Discharge Reconciliation

19 Launch discharge medication reconciliation (ORM) from new Discharge Note

New Quest Tools - ORM

20 Discharge medication reconciliation Select here for discharge reconciliation.

Status of medication reconciliation displays

Discharge Reconciliation

21 ITEMS TO RECONCILE= active inpatient and pre-admission medications If home medications prior to admission were incomplete, add or edit here e-Rx new discharge prescriptions here After discharge reconciliation, the new home medication list at discharge will display on right side column

Discharge Reconciliation

22 There are also quick action buttons for each medication in Discharge Reconciliation that are only enabled if there is a match in Prescription Writer for “quick prescription”: Continue at home w/o Rx “quick” discharge e-Rx Not required or stop If not enabled, you can still use the menu options to reconcile or prescribe:

Discharge Reconciliation

23 Home medication that was not continued as inpatient order Home medication that was converted to inpatient order Discharge reconciliation options for inpatient medication Discharge reconciliation options for pre-admission home medication

New Quest Tools - ORM

24 Choose expanded view in Format Layout to see all drugs House/pill = home medication House/pill = home medication Pill indicates inpatient medication

New Quest Tools - ORM

25 Choose expanded view in Format Layout to see all drugs House/pill = home medication Both versions expanded Inpatient medication

Discharge Reconciliation

26 Discharge medication reconciliation actions:  Tylenol was not ordered as inpatient drug but resumed at discharge   Oral Dilantin prior to admission was converted to IV as inpatient order and then back to oral with e-Rx at discharge IV Dilantin ordered as inpatient was not continued at discharge Inpatient IV Dilantin crossed off since not continued at discharge Pre-admission oral Dilantin is crossed off since new e-Rx created at discharge

Discharge Reconciliation

27 Add discharge medication instructions in note after ORM is “complete” Click to update discharge medication list in Discharge Note Continue Home Medications Tylenol 325 mg, 2 tablets every 4 hours as needed for pain or fever New Prescription Dilantin extended release 30 mg, 1 capsule at bedtime Sent to CVS, Orange (714) 555-5500 Instruction Categories:

Continue Home Medications

•These Home Medications Are Not Changed •These Home Medications Are Changed

New Prescription(s) Stop These Home Medications

Required for Discharge Instructions to print. Will only auto check if ORM is “complete”; otherwise, selection will clear

Discharge to Another Facility

28 Discharge to another facility does not require ORM Select to open active inpatient orders Required for Discharge Instructions to print

Printing Discharge Medications

29 Patient Discharge Instructions will not print until:  the status of medication reconciliation is complete and verified by Pharmacy for patients going to home, B&C, AL, etc. or  Discharge Note indicates that transfer orders are “complete” for patients discharging to another facility (SNF, LTAC, or other acute care setting).

 New prescriptions or any updates to the medication list after the status of medication reconciliation is completed will cause it to

become “incomplete” again

  Discharge medication reconciliation needs to be re-done for any new Rx Discharge medication list needs to be refreshed in Discharge Note

Re-do Discharge Reconciliation

30 A reconciliation can be reset to incomplete if saved in error or additional information was received. Re-launch ORM: 1) Select “View/Maintain History” tab 2) Select “Discharge” Reconciliation Type 3) Click “Set to Incomplete” and return to “Reconciliation Orders” tab

Summary of Key Points

31 Admission Medication History:   You can update the home medication list via OMR while in the H&P note and pull that list into your note.

Indicates the home medication list, collected by the nurse, is complete Medication Reconciliation:   Admission reconciliation is to be done within 24 hours of admit Remember to hover over the medication list to use the floating menu arrow to select reconciliation options

Summary of Key Points

32 Discharge:   Discharge medication reconciliation (ORM) automatically updates Prescription Writer and the medication list on the patient’s Discharge Instructions In the Discharge Note for patients transferred to another facility, you are directed to review and select appropriate current orders to be continued. • • This constitutes the Discharge Order/Treatment Plan that includes medications Medication reconciliation (ORM) is not done on these types of discharges

Summary of Key Points

33 Discharge (cont.):  New prescriptions or edits in Prescription Writer will reset the discharge medication reconciliation to an incomplete status.

• Return to the Discharge Note, • Launch medication reconciliation (ORM) and complete it,  • “Refresh” medication list in the Discharge Note Nursing will not be able to discharge the patient until medication reconciliation and Pharmacy review is complete.

• Discharge Instructions will not print until reconciliation is complete

Medication Reconciliation - Adult

34 Please make selection:  End training  Review Adult patient care admission medication reconciliation  Review Adult patient care discharge medication reconciliation  Neonatal patient care

Admission to hospital Everyone has a role

UCI Process - Neonatal Care

35 Obtain/document medication Hx If transfer, physician/NP/PA gets medication Hx from family and/or transfer records and documents medication list in H&P and/or OMR If admitted from home, nurse gets medication Hx from family, H&P, and QUEST tools and documents medication list in OMR with status of review Reconcile home/inpatient medication Physician/NP/PA uses medication Hx to order inpatient medications

Documenting Home Medications

36 Updating the home medication list in Quest tools maintains a consistent list of home medications that can be referenced in the Clinical Summary Medication Reconciliation view Status of home medication list is indicated

+

Add home medication

New Quest Tools - O

M

R

37 Home Med Review status Update status of home medication list: taking, not taking, unknown, or incomplete Edit Pharmacy info Mark as reviewed

?

Needs follow-up for incomplete info No longer taking Edit medication dose or frequency

Discharge Medication Reconciliation - O

R

M

38 Launch discharge medication reconciliation Select here for discharge reconciliation.

Status of medication reconciliation displays

Discharge Reconciliation

39 ITEMS TO RECONCILE= active inpatient and pre-admission medications If home medications prior to admission were incomplete, add or edit here e-Rx new discharge prescriptions here After discharge reconciliation, the new home medication list at discharge will display on right side column

Discharge Reconciliation

40 There are also quick action buttons for each medication in Discharge Reconciliation that are only enabled if there is a match in Prescription Writer for “quick prescription”: Continue at home w/o Rx “quick” discharge e-Rx Not required or stop If not enabled, you can still use the menu options to reconcile or prescribe:

Discharge Reconciliation

41 Home medication that was not continued as inpatient order Home medication that was converted to inpatient order Discharge reconciliation options for inpatient medication Discharge reconciliation options for pre-admission home medication

New Quest Tools - ORM

42 Choose expanded view in Format Layout to see all drugs House/pill = home medication House/pill = home medication Pill indicates inpatient medication

New Quest Tools - ORM

43 Choose expanded view in Format Layout to see all drugs House/pill = home medication Both versions expanded Inpatient medication

Discharge Reconciliation

44 Discharge medication reconciliation actions:  Tylenol was not ordered as inpatient drug but resumed at discharge   Oral Dilantin prior to admission was converted to IV as inpatient order and then back to oral with e-Rx at discharge IV Dilantin ordered as inpatient was not continued at discharge Inpatient IV Dilantin crossed off since not continued at discharge Pre-admission oral Dilantin is crossed off since new e-Rx created at discharge

Re-do Discharge Reconciliation

45 A reconciliation can be reset to incomplete if saved in error or additional information was received. Re-launch ORM: 1) Select “View/Maintain History” tab 2) Select “Discharge” Reconciliation Type 3) Click “Set to Incomplete” and return to “Reconciliation Orders” tab

Medication Reconciliation Neonatal

46 Please make selection:  End training  Review Adult patient care admission medication reconciliation  Review Adult patient care discharge medication reconciliation  Review Neonatal patient care

References

47 [1] Pentecost MJ. "Improving health care quality: current concepts," Permanente Journal, 2007 Winter; 11(1): 75-8. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3061389/ . Accessed May 13, 2013.

[2] The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alert. Issue 35. January 25, 2006. Available at: http://www. jointcommission.org/assets/1/18/SEA_35.PDF

. Accessed May 13, 2013.

[3] Institute for Healthcare Improvement. 5 Million Lives: Preventing Adverse Drug Events (Medication Reconciliation): How-to Guide. Available at: http://www.ihi.org/IHI/Programs/Campaign/ADEsMedReconciliation.htm

. Published Oct. 1, 2008. Accessed May 13, 2013.

[4] The Joint Commission. 2011 National Patient Safety Goals. Available at: http://www.jointcommission.org/assets/1/6/NPSG_EPs_Scoring_ HAP_20110706.pdf

. Accessed May 13, 2013.

[5] Budnitz DS, Pollock DA, Weidenbach KN, et al. “National surveillance of emergency department visits for outpatient adverse drug events,” JAMA, 2006; 296: 1858-66.