Medication Reconciliation

What steps does medication reconciliation involve?

- obtaining a complete list of medications

- Confirm medication list with patient

- Upon admission orders, reconcile against the med history to ensure no unintended differences

- review meds when transferring the patient from one unit to another

- before discharge, compare current med list to med list prior to admission- help to form patient's discharge med list

Why is medication reconciliation important?

- avoid medication errors

- avoid hospitalization/ readmission

- evaluate safety and efficacy

- evaluate adherence

What are the 3 crucial times medication reconciliation should be performed?

- admission

- intra-hospital transfer

- discharge

Joint Commission process

1. develop a list of current meds

2. develop a list of meds to be prescribed

3. compare the two lists

4. make clinical decisions based on comparision

5. communicate the new list to the patient and appropriate caregivers

High-risk situations for medication reconciliation

- limited health literacy

- cognitively impaired patients

- external transfer cases

What fraction of the adult population had limited health literacy/

1/3

Cognitively impaired patients

- may say they often or always have someone help them read hospital materials

- may be a little bit or not at all confident filling out forms

- find it hard to answer complex questions

If cognitive impairment is a concern...

consider screening (Mini-Mental State exam- time consuming or Mini-Cog - quick <5min)

Why are external transfer cases so complex?

3 sources of information require reconciliation

what 3 sources are included in external transfer cases?

- patient's list of home medication

- medications being administered at outside hospital prior to transfer

- medications ordered at receiving hospital

Medication reconciliation profile tab

document and update current medications, accessible by all disciplines

current medications include

- prescription meds

- OTCs

- vitamins

- herbs

- nutraceuticals

- respiratory medications

Full dosing information includes

- name

- strength

- formulation

- dose

- route

- frequency

- last dose taken

Medical history prompts

- use open/closed questions

- question route other than oral

- medications for medical conditions

- types of physicians that prescribe

- when they take the medication (day, week, month, prn)

- ask if they have started new medications, stopped medications, or made changes

- ask patient to describe medication by color, size, shape etc

Prompts for OTCs

What to take for (blank)?

You should verify the medication list after...

admission interview, verifying at a later point may increase accuracy

other sources for informaiton

- family/caregiver

- medication bottles

- community pharmacy

- patient PCP or specialty

- past medical history

- patient's own medication list

Internal transfer medication reconciliation

- movement/transfer level of care

- changing health status

- geriatric patients

- changes in organ function

What is the most common discrepancy?

error of omission

What changes in organ function require movement/ transfer level of care?

- renal function

- hepatic function

What are the steps in an internal transfer medication reconciliation?

1. Review the comprehensive admission medication list with active inpatient orders

2. Avoid reconciliation errors

3. Review the current inpatient medication list in the clinical context

Review the comprehensive admission medication list with active inpatient orders

- identify discrepancies between the admission list and the current inpatient orders

- evaluate clinical rationale for temporarily holding medications

- assure clear communication with EMR

How to avoid reconciliation errors?

- assure the admission list is accurate

- follow-up if needed

Review the current inpatient medication list in a clinical context

- consider patient and disease factors

- identify any medication-related problems

- document findings and interventions

Discharge medication reconciliation

- comparative review- admission medication list, inpatient orders, and discharge medication list

- assure patient/ caregiver understanding

- handoff to PCP and outpatient pharmacy

A comparative review at discharge means to review....

- admission medication list

- inpatient orders

- discharge medication list

What should you do in a comparative review of admission, inpatient, and discharge medications?

- identify discrepancies between admission meds and current inpatient orders

- evaluate clinical rationale for temporary holding inpatient meds

- assure clear communication

At discharge, how should you assure patient/ caregiver understanding?

- education: new meds, disease states, patient concerns

- confirm education using "teach back"

- counsel on adverse effects of medications

- assess health literacy

During discharge handoff to PCP/ outpatient pharmacy includes...

- assuring prescriptions can be filled

- multidisciplinary, collaborative effort

Settings for discharge follow-up

in-home or telephone

Discharge follow-up can be ....

time consuming

Tips for phone call follow-up

- confirm best day to call

- confirm phone number

- arrange interpreter services prior to making the call

- review medications: pre-admission> hospital > discharge

- use teach back

*** Medication reconiliation is a complex process that involves all the below steps EXCEPT...

a. obtaining complete list of medications upon the patient's admission

b. confirm this documented medication list with the patient to ensure accuracy

c. upon admission orders, reconile against med history to ensure no unintended differences

d. ensuring that the patient can obtain the medications at the lowest possible cost

e. upon admission orders, reconile against med history to ensure no unintended differences

d. ensuring the patient can obtain the medications at the lowest possible cost

3 multiple choice options

***When are the 3 crucial times when medication reconciliation should be performed?

admission, intra-hospital transfer, discharge

3 multiple choice options

***T/F : A patient with limited health literacy is fairly easy to identify. Patients who are well-educated always display a high degree of health literacy over patients who are not well-educated.

False

1 multiple choice option

***Which of the following questions, when conducting a patient interview for medication reconciliation, are in the correct format?

a. What do you take for your high cholesterol?

b. Does your arthritis doctor prescribe anything for you?

c. Do you put any medication on your skin?

e. Do you take any over-the-counter medications?

a. What do you take for your high cholesterol?

b. Does your arthritis doctor prescribe anything for you?

c. Do you put any medication on your skin?

e. Do you take any over-the-counter medications?

3 multiple choice options

T/F The patient's spouse/ significant other is a good source to use when performing medication reconciliation.

True

1 multiple choice option