Medication Reconciliation

Medication Reconciliation

Medication reconciliation is a process used to prevent medication errors and ensure that a patient’s current medication regimen is accurately documented during transitions of care. While it is commonly associated with hospitals, it is not exclusive to hospitals.

The goal of medication reconciliation is to prevent discrepancies in medication lists and avoid adverse drug events due to incomplete or inaccurate medication information. It promotes patient safety and improves communication among healthcare providers across various settings, ultimately leading to better healthcare outcomes.

Where Does It Occur?

Hospitals:

Medication reconciliation is extensively practiced in hospitals during admissions, transfers, and discharges, as these are critical points where medication information can be prone to errors.

Primary Care Settings:

Medication reconciliation is crucial in primary care clinics, where patients may receive prescriptions from multiple providers or change medications over time.

Outpatient Clinics:

Ambulatory care facilities, such as specialty clinics or community health centers, also conduct medication reconciliation to ensure patients’ medication lists are up-to-date.

Long-term Care Facilities:

Nursing homes and assisted living facilities use medication reconciliation to manage medications for elderly or long-term residents.

Home Health Care:

When patients transition from hospitals to home care, medication reconciliation ensures continuity and safety.

Pharmacies:

Pharmacies play a vital role in medication reconciliation by reviewing patients’ medication histories and reconciling prescriptions during dispensing.

Emergency Departments:

When patients arrive at the emergency department, medication reconciliation is essential to provide immediate and accurate care.

DURs

Drug Utilization Review (DUR): Scans the patient profile to identify any possible interactions/concerns that could occur as a result of the new prescription

  • Allergies

  • Adverse drug reactions (ADR)

  • Medical conditions

  • Duplication

  • Subtherapeutic or toxic doses

  • Drug Interactions

  • Vulnerable patient populations

  • A clinical DUR will give alerts/codes to alert the pharmacists to a potential adverse drug reaction

  • DURs help address two main practice issues:

    1. No one can remember all information provided

    2. Patients often go to multiple pharmacies and physicians

  • Pharmacy software catches issues regarding the patient profile

  • Insurance software catches problems with medications received at other pharmacies

  • Notifications are categorized by potential severity: mild, moderate, and severe

Three Outcomes:

  1. Contact prescriber

  2. Counsel patient on potential issues prior to dispensing

  3. Override DUR and fill RX as is

What is the role of the pharmacy technician?

  • To obtain the patient’s pharmacological history

  • Contact other health care facilities, pharmacies, and providers for medical records

  • Meet with patients to assess their medication adherence and document any discrepancies for the pharmacist to review

  • Forward any medical concerns or medication questions to the pharmacist

Review of Medication Reconciliation

  • Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. This process comprises five steps:

    Step 1: Develop a list of current medications

    Step 2: Develop a list of medications to be prescribed

    Step 3: Compare the medications on the two lists

    Step 4: Make clinical decisions based on the comparison

    Step 5: Communicate the new list to appropriate caregivers and to the patient

Medication Selection

1 in 4 filing errors is due to confusion of medication names. This is preventable when using NDC checks.

Possible errors can occur in stock selection: wrong dose, wrong package size, products that look alike, LASA, different formulations (SR, XL, XR, DR)

Stock Selection and Medication Preparation

  1. Retrieve correct stock bottle and verify NDC

  2. Select the appropriate size medication container

  3. Fill the prescription with appropriate number of units

  4. Label the bottle

  5. Return stock bottle to proper location

Dosage Forms/Dispensing

Tablets and Capsules: Most common drug form; clean the trays and spatulas with 70% isopropyl alcohol throughout the day. The powder residue is known to cause allergic rxns (sulfa, pen, ASA)

Liquids: Sometimes dispensed in original containers or poured into dispensing bottle; reconstituted liquids; flavoring

Choose proper medication container: vials or bottles; amber colored; child-resistant containers

Handling Prepackaged Drugs

Manufacturer prepackaging is provided for prescription products such as otics, ophthalmics, suppositories, creams, ointments, respiratory and nebulizer drugs, syringes, MDI, and oral contraceptives. These are commercially available as Unit-of-Use Packaging:

  • Fixed number of dosage units, sealed together in prepackaging

  • The prescription label is attached directly to the product or box

  • Simplifies the filing process by eliminating the counting step

  • The pharmacist must still check and approve the medication label, and ensure the proper drug, dosage form, and amount are chosen

Unit-Dose Packaging (single dose): Each unit dose of a tablet or capsule is a single dosage that is individually packaged in sealed foil and considered tamper-resistant. When dispensing these are usually placed in a vial or resealable bag with the prescription label attached. The unit-dose packaging label must include the manufacturer’s name, lot number, and expiration date in addition to the drug’s name and strength

ex) Ondansetron 4 mg ODT, suppositories, migraine meds

Automated Filing Technology

  • High volume pharmacies

  • Mail order pharmacies

  • Provides greater speed and accuracy in filling

  • Lowers cost per prescription by reducing manual fills

  • Reduces the time in counting, labeling

  • Increase in medication safety by integrating barcode technologies

Automated Scales

  • Medications that often require over 100 units

  • Never for controlled drugs

  • Must be calibrated and documented daily

  • Linked to DBMS

Internal scales that take into account the weight per unit of an individual tablet or capsule based on 10 dosage units, however, are not 100% accurate

Or

Visual-precision counting equipment (Eyecon), 99.99% accurate; uses scanner technology

Technician and Accuracy Checks

  • Check NDC three times

    1. Stock Bottle when initially pulled from inventory

    2. Time of preparation

    3. Check again when returning to the shelf

Customer Education Resources

Medication Container Labels: Reinforce dosage instructions of the prescriber

Take as Directed (TAD):

  1. Verify that prescriber gave the pt sufficient directions and match with usual directions

  2. Call prescriber for specific directions, document on RX

  3. If left TAD have RPh counsel patient on use

Medication Container Label

  • Prescription serial number

  • Pharmacy’s name, address, phone #

  • Patient name

  • Prescriber name

  • All directions for use given on RX

  • Medication strength

  • Drug manufacturer’s name

  • Drug quantity

  • Drug expiration date or date after which drug should not be used

  • Initials of licensed RPh

  • Number of refills

  • All necessary auxiliary

Auxiliary Labels

  • Colorful label used to highlight, provide additional information or reinforce information

  • Must prioritize which stickers to use because of limited space

  • Never place stickers over drug names or expiration dates

  • CII - V must have transfer warning

Patient Package Inserts

Patient Package Inserts (PPIs) are required by the FDA for some potentially dangerous drugs and have information for patients on how to safely use the medication. Oral contraceptives and estrogen-containing products are types of medications with PPIs; PPIs must be provided with the first dispensing and also with refills if 30 days has passed since the patient received a PPI. PPIs are part of the FDA-approved labeling.

Medication Information Sheet

Preprinted sheet from the manufacturer or from the pharmacy software. Goes out with each new prescription. Tell the patient how to safely take the medication and what to expect and watch for. May also include product identification.

Ingredient name, common uses, before using the medication, how to use this medication, cautions, possible SEs, overuse, additional information

Medication Guides (Medguides)

  • Enlarged FDA boxed warnings that advise consumers on potential adverse reactions or safe usage instructions

  • MED Guides go into more depth than information sheets

  • NSAIDs, antidepressants, birth control

  • Goes to patient with each fill

  • If not dispensed pharmacy may be subject to fines

REMS

Targeted Risk Evaluation and Mitigation Strategies

  • Certain drugs that are particularly dangerous for certain populations

  • The FDA requires the manufacturers to develop extra strategies to ensure that the benefits of the drugs outweigh the risk

  • These high-risk drugs will require additional verbal written communication and monitoring

  • Patients, prescribers, and pharmacies must be registered or certified, in order to, receive, prescribe or dispense these drugs

  • ex) Accutane (isotretinoin)/Ipledge, Bydureon, Suboxone, and Tikosyn

The Pharmacist’s Final Check

  • Pharmacist checks each prescription before it is dispensed

  • The pharmacist makes sure the prescription was entered correctly, the correct drug was selected, the container is labeled correctly and the correct quantity was filled for the correct patient

  • Pharmacist may add auxiliary labels, as needed

Dispensing to the Patient

  • After final verification of the prescription, it is ready for dispensing to the patient. Pt often receives a text or phone call notifying RX is ready for P/U

  • Completed prescriptions are usually stored alphabetically

  • Patients generally have 14 days to pick up a prescription before it is returned to stock. Insurance claims must be reversed.

  • Insulin and suppositories should be stored in a refrigerator once the prescription is verified

  • Antibiotic suspensions must be mixed just prior to dispensing. SHAKE WELL.

  • Medical errors often occur at pick-up. Verify the correct patient is receiving the medication using the patient’s address and birth date.

  • Ask for a photo ID when dispensing controlled substances. Signature required.

  • Let patient know if the RX is a partial fill or if there has been a change in the manufacturer

  • Offer the patient verbal counseling from the pharmacist

  • Pharmacy technicians are not allowed to provide counseling

Additional Health Services in Community Pharmacy

  • Medication Therapy Management Services

  • Vaccinations

  • Blood pressure Checks

  • Blood glucose Checks

  • Point-of-Care testing

  • Smoking cessation