Medication Reconciliation

1. Medication Reconciliation Prepared by: Nehad Ahmed

2. What is Medication Reconciliation? • Medication Reconciliation is a formal process in which healthcare providers partner with patients and their families to ensure accurate and complete medication information transfer at interfaces of care. This includes admission and discharge from a hospital or changes in care setting, service, or level of care.

3. The Medication Reconciliation Process • The process of medication reconciliation involves the following key components: • Obtaining the most complete and accurate list possible of the patient’s current regularly taken medications, known as the Best Possible Medication History (BPMH). 2. Using the BPMH when writing admission, transfer and discharge medication orders.

4. 3. Comparing the BPMH with the admission, transfer or discharge medication orders, identifying and bringing any discrepancies to the attention of the team and, if appropriate, making changes to the orders and documenting all changes.

5. Goal of Medication Reconciliation • The ultimate goal of medication reconciliation is to prevent adverse drug events (ADEs) at all interfaces of care (admission, transfer and discharge), for all patients. • The aim is to eliminate undocumented intentional discrepancies and unintentional discrepancies by reconciling all medications, at all interfaces of care.

6. An undocumented intentional discrepancy occurs when the prescriber (usually the physician) intentionally adds, changes or discontinues a medication the patient was taking prior to admission but this is not clearly documented in the patient’s medical record. • An unintentional discrepancy occurs when the prescriber (usually the physician) unintentionally changes, adds or omits a medication the patient was taking prior to admission.

7. Preventing of Medication Errors Types of medication errors that can be prevented by reconciling medications may include: • failure to prescribe clinically important home medications while in hospital • incorrect doses or dosage forms • missed or duplicated doses resulting from inaccurate medication records

8. failure to clearly specify which home medications should be resumed and/or discontinued at home after hospital discharge • duplicate therapy at discharge (result of brand/generic name combinations or hospital formulary substitutions)

9. What is the Impact of Medication Reconciliation? • The medication reconciliation process is a cost-effective strategy to reduce medication discrepancies and potential adverse drug events (ADEs) as patients move through interfaces of care. • There is evidence that a successful medication reconciliation process can reduce workload and rework associated with patient medication management

10. Who Should be Involved in Medication Reconciliation? • The medication reconciliation process is a shared responsibility of healthcare providers in collaboration with patients and families. It requires a team approach including nurses, pharmacists, physicians and other healthcare providers.

11. The actual roles and responsibilities for each discipline and clinician are based on the team’s optimal medication reconciliation practice model which takes into account available staffing resources. Effective models differ from hospital to hospital and within a hospital from team to team.

12. Patients and families are the central resource to communicate their own personal medication taking practices and assist by providing medication vials and lists. • It is very important that patients and their families understand the purpose of their medications and how to take them.

13. The pharmacist’s role in medication reconciliation is to coordinate the process. The pharmacist, wherever possible, should take primary responsibility for ensuring proper communication of medication information to patients and other healthcare providers on admission, transfer and discharge. • The pharmacist also ensures that medications are selected and ordered appropriately based on the patient’s clinical condition and other factors.

14. The physician’s role in medication reconciliation is to ensure that the patient’s medication orders on admission, transfer and discharge are completed as completely and accurately as possible. Any changes to medications should be documented in the chart and any discrepancies resolved as soon as possible.

15. The nurse’s role in the medication reconciliation process is essential because he must have a good understanding of all the medications a patient is to receive and why. • Also, certain medications that the patient was using at home may not be supplied by the pharmacy because they are on the hospital formulary. This requires communication between the pharmacist and the nurse to ensure that any “patient’s own” medications are identified, stored and administered safely.

16. How to Obtain the Best Possible Medication History (BPMH) • A Best Possible Medication History (BPMH) is a medication history obtained by a healthcare provider which includes a thorough history of all regular medication use (prescribed and non-prescribed), using a number of different sources of information. • The BPMH is different and more comprehensive than a routine primary medication history (which is often a quick patient medication history).

17. The BPMH involves a: • Patient medication interview where possible. • Verification of medication information with more than one source as appropriate including: • family or caregiver • community pharmacists and physicians • inspection of medication vials • patient medication lists

18. medication profile from other facilities • previous patient health records

19. The BPMH includes drug name, dose, frequency and route of medications a patient is currently taking, even though it may be different from what was actually prescribed. Using tools such as a guide to gather the BPMH may be helpful for accuracy and efficiency. • If a patient is unable to participate in a medication interview, other sources may be utilized to obtain medication histories or clarify conflicting information. Other sources should never be a substitute for a thorough patient and/or family medication interview.

20. For patients who present prescription bottles and/or a medication list, each individual medication and corresponding dosing instruction should be verified, if possible. • Frequently, patients take medications differently than what is reflected on the prescription label. Also, patients may not have updated their personal list with newly prescribed medications.

21. Where should the BPMH be documented? • The BPMH can be documented in a paper-based or electronic format. It should be placed in a highly visible place in the patient’s medical record for all healthcare providers to access. There are many examples of BPMH forms that have been developed by different healthcare organizations.

22. When should the BPMH be completed? • The BPMH should be completed as soon as possible after the decision to admit the patient has been made, and identify and reconcile discrepancies within the first 24 hours of admission. • Admission medication reconciliation processes generally fit into two models: the proactive process, the retroactive process or a combination of the two. Each team will need to determine what best practice works best for them based on staffing and patient characteristics.

23. In the proactive process, the BPMH is conducted prior to (e.g., in pre-admission clinic or emergency department) or upon the patient’s arrival on the unit and is used by the prescriber to write the AMOs. • Some teams have created paper based or electronic formats to document the BPMH that leads to AMOs by providing room for the prescriber to indicate whether the medications should be continued, discontinued or modified

24. In the retroactive process, the BPMH is conducted after the AMOs are written. The retroactive process is used when staff are unavailable to perform a BPMH upon admission, the patient is too ill or complex, or there is incomplete information available to complete a BPMH prior to the AMOs. • The BPMH should be conducted within 24 hours of admission.

25. Who should complete the BPMH? • The BPMH may be completed by any healthcare provider (e.g. doctor, nurse, pharmacist) who: • Has received formal training on how to complete a BPMH. • Follows a systematic process such as a BPMH interview guide where possible. • Is conscientious, responsible and accountable in conducting the BPMH process.

26. How to Identify and Reconcile Discrepancies • Differences (discrepancies) between AMOs and the BPMH can be divided into three main categories: documented intentional, undocumented intentional or unintentional.

27. Documented Intentional discrepancy: prescriber intentionally adds, changes or discontinues a medication and this is clearly documented. This is considered the ‘best practice’ in medication reconciliation. • Example: a patient is admitted with pneumonia and started on an antibiotic which they were not on at home. This is clearly documented on the chart and is an intentional discrepancy.

28. Undocumented intentional discrepancy: prescriber intentionally adds, changes or discontinues a medication but this is not clearly documented in the patient’s medical record. • Unintentional discrepancy: prescriber unintentionally changes or omits a medication the patient was taking prior to admission.

29. In order to determine whether a discrepancy is unintentional or an undocumented intentional, the information should be clarified with the prescriber. The clarification can be done in person, by email/fax or phone. • If the discrepancy was intentional, then the proper documentation is required on the chart. If the discrepancy is unintentional, then the prescriber can resolve the discrepancy by writing a new order.

30. The Medication Reconciliation Process

31. Medication Reconciliation at Transfer Transfer is an interface of care associated with a change in the patient’s status and may include: • change in responsible medical service or level of care • post-operative transfer • transfer between units

32. The goal of medication reconciliation at transfer is to ensure all medications are appropriate for the patient’s new status of care. The process involves assessing and accounting for: • medications the patient is taking prior to admission (BPMH) • medications the patient has received since admission (MAR - Medication Administration Record) • new post-transfer medication orders (includes new, discontinued and changed medications upon transfer)

33. The team makes decisions about the appropriateness of continuing existing hospital medications, as well as assessing the need to resume or discontinue pre-admission medications. • Medication reconciliation at transfer ensures that changes are intentional and discrepancies are identified and resolved. This should result in avoidance of therapeutic duplications, omissions, unnecessary medications and confusion.

34. Medication Reconciliation at Transfer Model

35. Medication Reconciliation at Discharge Goal of Medication Reconciliation at Discharge • The goal of medication reconciliation at discharge is to reconcile the medications the patient was taking prior to admission (BPMH) and those initiated in hospital, with the medications they should be taking post-discharge to ensure all changes are intentional and that discrepancies are resolved prior to discharge. • This should result in avoidance of therapeutic duplications, omissions, unnecessary medications and confusion.

36. Discharge medication reconciliation clarifies the medications the patient should be taking post-discharge by reviewing: • medications the patient was taking prior to admission (BPMH) • current medications (previous 24-hour MAR) • new post-discharge medications

37. Process for Medication Reconciliation at Discharge • An inter-professional, systematic, integrated strategy will reduce medication discrepancies at hospital discharge. This strategy should include tools to support healthcare providers and the patient with discharge reconciliation and should integrate and clarify medication information from all sources. • The result should be clear and comprehensive information for the patient and other care providers about post-discharge medications.

38. The Best Possible Medication Discharge Plan (BPMDP) is the most appropriate and accurate list of medications the patient should be taking after discharge. • Using the Best Possible Medication History (BPMH) and the previous 24-hour medication administration record (MAR) as references, create the BPMDP by evaluating and accounting for: 1. New medications started in hospital 2. Discontinued medications (from BPMH)

39. 3. Adjusted medications (from BPMH) 4. Unchanged medications that are to be continued (from BPMH) 5. Medications held in hospital 6. Non-formulary/formulary adjustments made in hospital 7. New medications started upon discharge 8. Additional comments as appropriate (e.g., status of herbal medications/supplements or medications to be taken at the patient’s discretion)

40. The BPMDP should be communicated to the: • patient • community prescriber/family physician • community pharmacy • other healthcare facility or service (e.g., long-term care or complex continuing care institution)

41. Clear patient communication is essential. Each time a patient moves from one healthcare facility to another or to home, providers should review with the patient and/or responsible family member the previous medication regimen alongside the list of medication prescribed at discharge and reconcile the differences. • This process should take place both prior to leaving the hospital and again promptly after transition to the new setting of care.

42. Medication Reconciliation at Discharge Model

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