1. Medication Reconciliation Using PharmaNet-based Forms …It’s about the conversation. 2010

2. Outline • Why reconcile? • What is Medication Reconciliation? • Change of Practice • PharmaNet-based Med Rec Forms • Obtaining a Best Possible Medication History (BPMH) • Documenting the BPMH on the PharmaNet-based Med Rec Form • Processing Medication ReconciliationOrders

3. Why Reconcile? • Over half of medication errors occur at the interfaces of care Rozich JD, Reser RK. Medication Safety: One Organization’s Approach to the Challenge. J Clin Outcomes Manage. 2001;8(10): 27-34 • An up-to-date and accurate medication list is essential to ensure safe prescribing in any setting Safer Healthcare Now! Getting Started Kit: Medication Reconciliation Prevention of Adverse Drug Events

4. Medication Reconciliation • Working Definition: …a formal, systematic process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at transitions of care.

5. Medication Reconciliation • Working Definition: …a formal, systematic process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at transitions of care.

6. Medication Reconciliation • PreventUnintentional Discrepancies • Document Intentional Discrepancies

7. Medication Reconciliation

8. Medication Reconciliation • Three step process: • Collection • Clarification • Reconciliation  Medication Orders Best Possible Medication History(BPMH)

9. Change of Practice (Admission) Current state • Multiple individuals take medication histories and document them in different locations in the clinical record • Medication orders are written on a separate form • Discrepancies occur without any effective way of identifying or resolving them Future state • One individual will obtain and document the best possible medication history (BPMH) • The prescriber will confirm/write medication orderson the same form to increase transparency and eliminate transcription errors

10. Standard Forms • Use data in existing databases to: • Minimize transcription • Ensure no active orders are overlooked • Formatted to support three-step process: • Collection (existing data) • Clarification (modified/additional data) • Reconciliation  medication orders • Transparent process • Apparent to all subsequent caregivers • Documentation of BPMH in single location at admission which can be referred to at discharge

11. Medication Reconciliation at Admission • Three step process: • Collection • Clarification • Reconciliation

12. COLLECTION CLARIFICATION RECONCILIATION

13. CLARIFICATION CLARIFICATION COLLECTION RECONCILIATION

14. Best Possible Medication History • An up-to-date and accurate medication list is essential to ensure safe prescribing in any setting Safer Healthcare Now! Getting Started Kit: Medication Reconciliation Prevention of Adverse Drug Events • Goal is to determine how a patients is actually using their medications (versus how they were prescribed) • Three steps: • Preparation • Conversation • Documentation • Tools available at: http://vchconnect/programs_services/regional_pharmacy/medication_reconciliation/resources/page_69550.htm

17. Preparation • Review chart for clinical conditions and any medication lists obtained previously • Print and review the patient’s PharmaNet-based Medication Reconciliation Form from CareConnect

18. Limitations of PharmaNet • Record of prescriptions dispensed • Reflect current use of prescription medications less than 30% of the time Shalansky, S et al: Accuracy of a Prescription Claims Database for Medication Reconciliation for Outpatients with Heart Failure. Can J Hosp Pharm 2007;60(3):169-176 • Information in PharmaNet MUST be clarified/verified with the patient or caregiver

19. Limitations of PharmaNet • MAY contain discontinued medications • Does NOT contain • Updated administration instructions • Non-prescription drugs • Samples • Investigational/clinical trial drugs • Complementary and alternative therapies • Antiretrovirals, some chemotherapeutic agents and vaccines • Prescriptions obtained outside of BC or over the internet • Fraudulent use • Information in PharmaNet MUST be clarified/verified with the patient or caregiver

20. Printing PharmaNet-based Forms • Forms are accessed via CareConnect • Detailed instructions are available at:http://vchconnect/programs_services/regional_pharmacy/medication_reconciliation/page_67071.htm

21. Total Pages and Print Date Patient Identification

22. Interpreting PharmaNet Entries Generic name, strength and dosage form of medication Usage instructions Fill date Prescriber Prescription status Fill quantity

23. Preparation continued • Review chart for clinical conditions and any medication lists obtained previously • Print and review the patient’s PharmaNet-based Medication Reconciliation Form from CareConnect • Anticipate non-prescription medications based on clinical history + PharmaNet • Review any medication containers that the patient brought to hospital • Arrange for a translator or family member to assist if required

24. Conversation

25. Conversation • Introduction • Ask to see home medications if available • Ask patient to describe why and how they are taking each medication regardless of what is on the label or in PharmaNet • Ask specifically about: • nonprescription medications, especially • aspirin • analgesics (acetaminophen, ibuprofen) • vitamins, calcium, iron and other supplements • allergy medications, eye drops, creams, etc • Samples • Previous adverse effects (or lack of effect) of medications • Any further questions?

26. Conversation

27. Documentation

28. Documentation

29. Documentation – Peri-op

30. Reconciliation

31. Summary • Why reconcile? • What is Medication Reconciliation? • Change of Practice • PharmaNet-based Med Rec Forms • Obtaining a Best Possible Medication History (BPMH) • Documenting the BPMH on the PharmaNet-based Med Rec Form • Processing Medication ReconciliationOrders

32. Acknowledgements • Crystal Amos, Medication Safety Pharmacist, Vancouver Acute HSDA • Jane de Lemos, Coordinator, Professional Practice, VCH-PHC Pharmacy Services • Debbie Jeske, Interim Director, Peri-operative Services, Vancouver Acute HSDA • Elinor Orsini, Patient Services Coordinator, Preadmission Clinic, Vancouver Acute HSDA • Fruzsina Pataky, Medication Safety Coordinator, VCH-PHC Pharmacy Services