Medication Reconciliation

1. Medication Reconciliation Patty Grunwald, PharmD, BCPS Clinical Pharmacy Coordinator Frederick Memorial Hospital, Frederick, Maryland

2. JCAHO 2006 National Patient Safety Goal Goal 8 Accurately and completely reconcile medications across the continuum of care. • 8A Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. • 8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

3. Steps in Reconciliation Process • Develop complete and accurate medication list • Compare (reconcile) the listed medications with any new orders • Update the list as orders change • Communicate the updated list to the next provider of care.

4. When Should Reconciliation Occur? • Whenever the organization… “… refers or transfers a patient to another setting, service, practitioner, or level of care within or outside the organization.” • At a minimum… Any time the organization requires orders be rewritten Any time the Patient changes service, setting, provider or level of care and new medication orders are written • For transitions not involving new medications or rewriting of orders, the organization determines whether reconciliation must occur.

5. Roadblocks • Medical staff acceptance • Overcoming concerns related to the accuracy of solicited medication list • Ownership for medication oversight • “My patient-type is very unique” • “You just don’t understand” • Consistency among residents and physician extenders • Communication among consultants

6. Medication Reconciliation: Who’s Responsibility is it?

7. Problems With Getting Accurate List • Patient brings in incorrect list • Patient does not take what is marked on the bottle • Patient does not know what is on and family, pharmacy not available • Wrong name of med on ED sheet • Med bottles don’t jive with what the patient says • Patient is unable to tell you. No family available. MD on call does not know either. • Can’t call the pharmacy “after hours”

8. FMH Process • A work in progress • Three domains: • Admission • Transfer/re-order post-op • Discharge

9. FMH Form

10. FMH Form (con’t)

13. Medication Reconciliation Results

14. Number of Patients

15. Admissions Unit Pilot • Begins January 16, 2006 • Uses current workflow • Nurse will print form right before patient leaves unit • MD to review/sign within 24 hrs of admission • Expand to SDSS in January 2006

16. Plan for Transfers • Work in progress • Revise current transfer/reorder list to have the same information as medication reconciliation form • Will decrease physician time in reordering medications post-op

17. Plan for Discharges • Create a form based on the admission reconciliation form • Include lay language on how to take medication • Include statement to notify physicians of interchanges

18. Evaluation Process • 100% review during pilot • Thereafter, 25 cases per area per month • Data collected: • Number possible reconciliations • Percent charts with form • Percent with signed forms • Number home medications restarted • Number hospital medications DC’d

19. Contact Information • Phone: 240-566-3797 • E-mail: pgrunwald@fmh.org