Medication Reconciliation

MUSE 2006 Markham Stouffville

HospitalAlice Watt, B.Sc.Pharm

2006

A I M Med Rec - What is it? The Journey Toolbox

Admissions Transfers Discharge Reports

Lessons Learned

What is it? Medication

Reconciliation Process of :

1. Getting the Best Possible Med History

2. Using the BPMH to write admission orders

3. Identifying and reconciling discrepancies with the physician

Important for our patients because…

Saves lives - medication errors and adverse drug events.

The Journey

2002 2003 2004 2005 2006

Pilotproject

Getting Started

Data collection

Implementationin ER, 3E, ICU

Hospital-wideimplementation

Electronic record

PaperRecord

Toolbox

Admissions

Diagnosis/Surgical Procedure

Unit/Rm

Physician

Pharmacist to Do Warfarin Amino Phenytoin CADD Other: Computer Med Hx completed

NAME. (Place identification sticker here. )

Medical Conditions

Date of Admission

Ht ABW IBW DBW Age M F

Allergies

Barriers Social History From home From LTC/NH Other:

Smoking Never Former Current

Alcohol No use Social Abuse

Sub-stance

Meds Ordered on Admission

Meds Prior To Admission

Please See Computer Med Hx

if no

Dosage ordered by MD

Interventions

New Meds Started or Changes in Regimen or Discontinued by MD

Source of med info Patient Family Pharmacy GP Vials

Community Pharmacy/ Phone Number

Consent Obtained? Yes

Discharge Date/Plan

Medication Profile– Paper Record

Process Interventions

Medication History

Patient Name

Synthroid 0.1 mg PO daily

Metformin 500mg PO TID

Synthroid 0.1mg po dailyMetformin 500mg po tidccECASA 81 mg po daily

Medication Reconciliation Screen

Pill’s Pharmacy – (416) 333 - 9999Patient interviewDPV

Synthroid 0.1mg PO DAILY

Metformin 500mg PO TIDCC

EC ASA 81mgPO dailyY

N

Y U

D

Order Changed

Called MD

Not Necessary

Patient NamePre-set options

Patient Assessment

Patient Name

Counsel patient at discharge concerning

new BP meds

Speaks no english – Family to be present to help

translate

Visual FlowSheet - Reconciliation

Pre-op Medication Report

Medication Reconciliation Record and Doctor’s order

Transfers

Transfers

Medication orders are compared by physician at transfer points.ICU MedicineSurgery/Short Stay Rehab

Transfer Order Sheet

Warfarin Monitoring

Warfarin Monitoring - VFS

Discharge

Discharge

Admission Medication reconciliation helps at discharge

Work in progress PDRx

Discharge Medication ListDOCTOR:

LOCATION:

PATIENT:

Reports

Reports Monthly report for Safer Healthcare now Run by date Categories include :

Type of variances # of medications reconciled # of patients reconciled by ID number Time to reconcile vs. time of admission Time to reconcile each patient

Lessons Learned…

Trial and Error Task Force It’s a Team effort

Questions