1. 1 Medication Reconciliation: Opportunity to Improve Resident Safety

2. Overview and Objectives Following this session you will gain an understanding of how: To conduct a medication reconciliation on all new admissions and readmissions to long term care, To obtain a best possible medication history on each new resident Medication Reconciliation impacts on resident safety

3. Transitions in Care Long Term Care Home Care Acute Care Ambulatory Care

4. Impact The potential for medication errors and resident harm exists if medication histories are inaccurate and/or incomplete and are subsequently used to generate the resident's medication orders Lack of knowledge of resident’s medications at transition points (admission, transfer, discharge) is believed to be a key source of adverse events – Massachusetts Coalition for the Prevention of Medical Errors

5. Medication Reconciliation in Long Term Care Safer Health Care Now Video

6. What is Medication Reconciliation? Process of collecting and documenting complete medication and allergy histories from the resident and/or family. Process of comparing and deciding which medications should be continued, held, or discontinued on admission and at discharge. Includes communication between health care providers. Includes a commitment to review all medications at time of admission, transfers, and/or discharge. Intended to minimize potential harm from unintended discrepancies Timely process but well worth the time spent ~ leads to better resident outcomes.

7. What is Medication Reconciliation? Occurs at transitions and interfaces of care Indentifying discrepancies Resolving discrepancies Preventing adverse drug events by: –Eliminating undocumented intentional discrepancies –Eliminating all unintentional discrepancies

8. What is the Goal of Medication Reconciliation Eliminate unintentional discrepancies Decrease medication related adverse events Improve client safety

9. Why Perform Medication Reconciliation? Rate of medication errors in a 6 month period decreased by 70% after implementation of a medication reconciliation process at all phases of hospitalization - Rozich J.D. & Resar R. JCOM. 2001; 8: 27-34 Pharmacist participation on medical rounds and reconciliation and verification of patient medication profiles at interfaces of care greatly reduced medication errors - Scarsi, K et al. Am J Health-Syst Pharm. 2002; 59: 2089-92 One study found 94% of the patients had orders changed after an ICU stay. By reconciling all pre-hospital, ICU and discharge medication orders, nearly all medication errors in discharge prescribing were avoided - Provonost P, et al. Journal of Critical Care. 2003; 18:201-205.

10. Challenges Resident and/or advocates ability to recall medications, doses and/or frequency of use Stress of transitioning through the healthcare system Health Literacy Language barriers; cultural beliefs Relationship with the healthcare clinician who is obtaining the history

11. Challenges Interviewer’s skill level Time constraints Accuracy and completeness of medication histories obtained from other resources Accessibility of resident’s medication list during night/weekend hours

12. Sources of Information from Another LTCF or Hospital Previous 24-hours MAR Medication Profile Resident Assessment instrument (RAI) – standard screening/assessment tool LTC Pre-LTC/Hospital Medications

13. Four Steps: 1.Obtaining the Best Possible Medication History ( BPMH) 2.Identifying discrepancies 3.Reconciling discrepancies 4.Spreading processes to other transitions of care Steps to Conducting a Medication Reconciliation

14. Step 1. Collect an Accurate Allergy and Medication History Collect an Accurate Allergy and Medication History Taking a complete allergy and medication history is an essential step toward ensuring resident safety. The risk of preventable adverse medication events can be significantly decreased by knowing the complete medical history.

15. What is Defined as a Medication? Prescription medications Implanted pumps, Narcotics, etc Sample medications Vitamins Nutriceuticals Over-the-counter Radioactive medications Respiratory-related medications Parenteral nutrition Blood derivatives Intravenous solutions (plain or with additives) Any product designated as a drug Diagnostic and contrast agents

16. Overlooked and Easy to Forget Medications Implanted pumps Eye drops Nasal sprays Vitamins Herbals Homeopathic remedies Creams Narcotic Patches Over-The-Counter Samples Dental medications Inhalers Dietary supplements

17. Interviewing the Resident and / or family member 1.Ask about medications 2.Use open-ended questions. 3.Use nonbiased questions. 4.Pursue unclear answers. 5.Ask simple questions. 6.Review medications brought to the home on admission. 7.Prompt the resident/family for other medications. 8.Discuss allergies. 9.Investigate resident’s medication compliance.

18. Seeking Clarification 1.Obtain a detailed description of the medication from the resident/family. 2.Talk to any family members present or contact someone 3.Ask the pharmacist to call the resident’s pharmacy. 4.Contact the resident’s physician(s). 5.Obtain previous medical records and compare this with the admission orders.

19. Interviewing Strategies Introduce yourself Use open-ended questions Pursue unclear information until it is clarified Review any med wallet cards carrying by the resident or any list of meds brought with them.

20. Interviewing Strategies Don’t accept med lists without verifying the information with the resident, and/or caregiver Link medications to conditions Assess resident’s compliance by asking questions such as: –How do you take your medications? –Are there any medications that you have stopped taking? –Why did you stop them?

21. Additional Questions to Ask What does the tablet you are taking look like? What medication do you take for your heart problem? Are there medications that you take only sometimes or when you need them? How often do you take it? When was the last time you took it? Does your doctor give you any sample medications to take?

22. Sample Medication History Questions Let’s look at yesterday. Starting from when you woke, what was the first medication you took? –How many times a day did you take it? –What are you taking it for? –What other medications did you take?

23. What Information is Necessary about the Medications? Medication Name Dose (mg, tab, etc.) Route of Administration Frequency (How often?) What time of the day? When did you most recently take the medication - (date/time) Reasons for the medications

24. Sample Allergy History Questions What medication allergies or adverse drug reactions do you have? Educate the resident/family about the difference: –True Allergies cause reactions such as a rash, bronchospasm, itching, etc. –Adverse Drug Reactions are the patient’s response to the drug such as nausea, dry mouth, etc. What was the medication? When did this happen? What other types of allergies do you have; food, environmental?

25. Step 2. Identifying Discrepancies Cross check the admission orders against: –Previous MAR from discharging facility – specifically most recent medications given –CCAC MDS assessment forms – checking through all pages for any handwritten notes –Any previous orders/MARS, if a readmission –List of medications from resident/family

26. Identifying Discrepancies Refer to the arrival list when writing medication orders for admission, transfer, and discharge. Compare the arrival list with every medication ordered at admission or discharge and look for discrepancies Address ALL discrepancies with the physician

27. Step 3. Reconciling Discrepancies Share the List Upon admission/readmission, inform physician and pharmacist of any discrepancies Document any discrepancy in the admission progress notes When transferring, or discharging the resident to an outside facility, remember to provide: –A copy of the most recent MAR. –A copy of the transfer record. Discuss the discharge instructions with the resident and/or caregiver.

28. Step 4: Process Changes for Medication Reconciliation Establish the expectation that residents come with all their medications upon admission. Improve access to complete medication lists at admission, readmission, transfer and discharge.

29. Types of Medication Reconciliation Errors Improper dose/quantity Omission error Prescribing error Wrong drug Wrong time Extra dose Wrong resident Mislabeling Wrong administration technique Wrong dosage form Medmarx® reporting program

30. When do you Conduct a Medication Reconciliation? Admission Readmissi on Transfer back Discharge At all transfer points of care

31. Questions? 31