1. Tiffany Montoya, PharmD, PhC Lead Cardiology Pharmacist October 25, 2012

2.  The average hospitalized patient is subject to at least one medication error per day  Medication errors are the most common patient safety error  >40% of med errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients.  Of these errors, ~20% result in harm

3.  National Patient Safety Goal #3: Improving the safety of using medications  Requires that organizations “maintain and communicate accurate medication information” and “compare the medication information the patient brought to the hospital with the meds ordered for the patient by the hospital in order to identify and resolve discrepancies.”  Core Measures for Heart Failure  HF1: Written discharge instructions ▪ Patient must be discharge with a compete med rec list ▪ The discharge med list must match the discharge summary med list EXACTLY

4.  The process of comparing a patient’s medication orders to all of the medications that the patient has been taking. (The Joint Commission)  This process comprises 5 steps: 1. Develop a list of current meds 2. Develop a list of meds to be prescribed 3. Compare the meds on the two lists 4. Make clinical decisions based on the comparison 5. Communicate the new list to appropriate caregivers and to the patient

5. 1. Select “Medication List” tab on left Menu 2. Select “Customize View” 3. Move “Available Columns” to “Selected Columns” 4. Move “Type” up to top 5. “Group orders by:” VENUE 6. “Then by:” ACTIVE/INACTIVE 7. “Sort orders:” ORDER NAME 8. Ascending or descending---either one

6. 1. Select “Medication list” 2. Select “Customize View”

7. Select everything from “available columns” and move it to “selected columns” by selecting “Add”

8. Move “Type” up to top (just below “Quick Discontinue”)

9. “Group Orders By:” Active/Inactive

10. “Then By:” Venue “Sort orders by:” Details

11. “Ascending” or “Descending,” then “OK”

12. For in-house use, keep display set to “All Active Medications” Meds are now sorted by Active or Inactive and by Venue (IP/OP/Hx)

13. Note disclaimer statement- this function contains Rxs that have been e- scribed and filled by patient. Please be aware this is not all inclusive and info may be missing It is intended as an additional source of info and should not be used alone.

14. 1. Select “Medication List” 2. Select “Document Medication By Hx” 3. Select Add 4. Type the drug name in the “Find:” box 5. Select the desired drug from the list below 6. Select from the quick order sentences for dose, rout, and frequency 7. Select “OK” 8. Select “Done,” if no other meds need to be added 9. To view lower screen larger: Hover your mouse pointer over the bar, left click and move the bar up. 10. Fill out “Order details” under “Detail values” 11. Select “Document History” to complete order

15. Select “Medication List” then select “Document Medication by Hx”

16. Select “Add”

17. Type the drug name in the “Find:” box Then, select the desired drug from the list below

18. 1. Select from the quick order sentences for dose, route, and frequency 2. Select “OK”

19. Select “Done,” if no other meds need to be added

20. To view lower screen larger: Hover your mouse pointer over the bar, left click and move the bar up.

21. Fill out “Order details” under “Detail values” then select “Document History” to complete order.

22. Should be done when/if you discover that a patient is NOT taking a med previously free-texted into the list by another person. 1. Select “Medication List” 2. Select “Document Medication By Hx” 3. Hx meds will have a scroll icon 4. Right click on med to D/C 5. Select “Cancel/DC” 6. Select discontinue reason below 7. Finish by clicking “Sign”

23. Select “Medication List,” Then, Select “Document Med by Hx” above

24. Right Click on the med to D/C Select “Cancel/DC”

25. 2. Then select D/C reason under “Detail values” 1. Select “Cancel Reason” 3. Finish by selecting “Sign”

26. 1. Select Medication List 2. Click on “Reconciliation” 3. Select “Admission” from the drop down menu 4. Review all meds on this screen 5. Select the circle to identify which meds to continued on this admit and which should be d/c’d NOTE: Meds may be added & Power Plans may be managed from this view 6. The meds that have been selected to continue on this admission will be listed on the right 7. Make sure there are NO duplicate meds on this list 8. Select “Reconcile And Sign” to complete Admission Med Rec 9. “Admission Meds Rec” is now complete

27. 1. Select Medication List 2. Click on “Reconciliation” Then select “Admission” Admission Med Rec needs to be completed

28. Review all meds Select the circle to identify which meds to continued on this admit and which should be d/c’d =Hospital med =Historic med =Outpt Rx med =Part of a power plan =Med that needs to be reviewed Meds may be added & Power Plans may be managed from this view

29. The meds that have been selected to continue on this admission will be listed on the right Make sure there are NO duplicate meds on this list Select “Reconcile And Sign” to complete Admission Med Rec

30. “Admission Meds Rec” is now complete

31. 1. Select “Chart” 2. Click on “Depart Process” 3. Select “ Med Rec/DC Prescriptions” 4. Review all meds: Select the circle to identify which meds to: “Continue after discharge”, “Create New Rx”, or “Do not continue after Discharge” 5. Meds that have been selected to “continue after discharge” or “create new Rx” will be listed on the right 6. Make sure there are NO duplicate meds on this list; It should not include any pharmacy abbreviations; All meds should have name, dose, route, and frequency; It should include all meds that the patient should be discharged on (eg., home medications that were not changed, new medications…) 7. Any medication that has a blue circle with an “X” means information for that medication needs to be completed 8. Left click on the medication 9. Fill in any missing information for the prescription to be complete 10. Select “Reconcile And Sign” 11. Select “Sign” to complete med rec and to create a note in Powerchart with all the patients discharge information

32. Discharge Med Rec needs to be completed Select “Chart” then Select “Depart Process” Shortcut to “Depart Process”

33. Select “Med Rec/DC Prescriptions

34. Meds may be added & Power Plans may be managed from this view Review all meds Select the circle to identify which meds to “Continue After Discharge” “Create New Rx” Or “Do Not Continue After Discharge” Meds are listed in groups if there are multiple orders for the same med Home meds are automatically checked to “Continue After Discharge” Hospital meds are automatically checked “Do Not Continue After Discharge” Adjust all meds as appropriate =Hospital med =Historic med =Outpt Rx med =Part of a power plan

35.  If there are meds on the “Meds prior to discharge reconciliation” list that are SUSPENDED, they will have a bolded comment to the right (see above).  As long as these meds are “suspended”, they will not populate the final depart med list that is given to the patient.  You must address each of the suspended meds (usually by right clicking, resuming the order, then selecting the appropriate final action)

36. The meds that have been selected to continue after discharge will be listed on the right Make sure there are NO duplicate meds on this list It should not include any pharmacy abbreviations All medications should have name, dose, route, and frequency It should include all medications that the patient should be discharged on (eg., home medications that were not changed, new medications…) Any medication that has a blue circle with an “X” means information for that medication needs to be completed

37. 2 nd : Left click on the medication 3 rd : Fill in any missing information for the prescription to be completed 1 st : Select a printer or pharmacy to e-scribe

38. Select “Reconcile And Sign”

39. This should be the medication list that the patient is expected to be discharged with Select “Sign” to create a note in Powerchart with all the patients discharge information

40. The depart medication list that was finalized should be the second note in the group of most recently signed documents The medication list can be found under Clinical Notes  Inpatient Discharge Documents  Inpt Depart Summary

49. Percent

50.  Advancing Excellence in Health Care. Medication Reconciliation. Retrieved October 24, 2012, from http://www.psnet.ahrq.gov/primer.aspx?primerID=1.  Jane H. Barnsteiner. Chapter 38Medication Reconciliation. Patient Safety and Quality: An Evidence-Based Handbook for Nurses;(2):495-472.