1. Medication Reconciliation
Caroline Steward
APN, CCRN,CNN
Capital Health Regional Medical Center
Dialysis Services
5/16/19

2. Our Journey Today Recognize how data/research can impact practice.
Review an example of how practice can be changed thru governmental interventions
Recognize the impact of these interventions on your practice
Differentiate between a Medication Reconciliation and an Medication Review
Incorporate“Rights of MedRec” when evaluation your patients medications
Discuss examples of medication lists
5/16/19

3. JCAHO Sentinel Events (1995)
5 High Risk medication were linked to the highest risk for adverse events/death
Insulin
It is not unreasonable to consider that now with some many new anti diabetic agents now in use that this area has broadened in its’ impact
Opiates/ narcotics
The opioid crisis is upon us
Injectable Potassium (other electrolytes often included)
We often do not think about what impact changing concentration in dialysate as a potential for a Sentinel Event
We are also constantly giving medications that alter electrolytes (All of the MBD medications)
Anticoagulants- heparin
We certainly use lots of heparin in dialysis
But let’s not forget all the other antiplatelet and anticoagulants our patients also take (Plavix, ASA, Coumadin)
Saline solutions greater than 0.9% (NNS)
Interesting if you think back to when we used hypertonic saline (23.8%)
But more recently the changes in practice that no longer recommend sodium modeling of use of conductivity alterations(buttons)
The Joint Commission began to look at medication errors and in 1995 developed a list of high risk medications
As you can see we routinely use many of these medications during routine hemodialysis treatments
5/16/19

4. To Err Is Human Published 1999
BUILDING A SAFER HEALTH SYSTEM
Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.
Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments.
5/16/19

5. Institute of Medicine(IOM): Preventing Medication Errors (2006)
The average hospitalized patient is subject to at least one medication error per day.
This confirmed previous research findings that medication errors represent the most common patient safety error.
More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients.
Of these errors, about 20 percent are believed to result in harm.
Many of these errors would be averted if medication reconciliation processes were in place.
Agency for Healthcare Research and Quality (AHRQ)
5/16/19

6. Preventing Medication Errors: Quality Chasm Series
In 2007 a follow up report by the Institute of Medicine (IOM) medication errors remain extremely common, and the health care system can do much more to prevent them.
The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety.
These actions include having all US prescriptions written and dispensed electronically by 2010,
More widespread use of medication reconciliation, and additional research on drug errors and how to prevent them.
Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments.
Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Preventing Medication Errors: Quality Chasm Series. Classic Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007
Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals
5/16/19

7. Agency for Healthcare Research and Quality (AHRQ) Risks for Medication Errors and Adverse Drug Events (2019)
Care Setting also impacts Medication Error
Nearly 1/3 of all US citizens take 5 or more medications regularly
Due to widespread use of both prescription and non-prescription medications.
Accounting in 700,000 ED visits/year and 100,000 hospitalizations
5% of all hospitalized patients will experience a medication error
Patient in outpatient settings
In a study of 1200 outpatients followed for 4 weeks
25% had complications
Medications most often noted were
SSRI
Beta Blockers
ACE
NSAID
The authors felt that 1/3 of these complications were preventable
Opioid deaths are also a rising problem in the outpatient setting
Adverse Drug Events in Ambulatory Care information on outpatient setting
AHRQ Agency for Healthcare Research and Quality; Department of Health and Human Services, (.hhs.gov) (2019)
5/16/19

8. What does all of this have to do with Dialysis??
5/16/19

9. 5/16/19

10. 5/16/19

11. Medication Reconciliation (MedRec) (Reporting Measure)
Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Payment Year (PY) 2022 Measure Technical Specifications
Medication Reconciliation (MedRec) (Reporting Measure)
The percentage of patient-months for which medication reconciliation was performed and documented by an eligible professional (based on NQF #2988).
1. Medication reconciliation is a measure that assesses whether a facility has appropriately evaluated a patient’s medications.
2. For the purposes of this measure, “eligible professional” is defined as a physician, nurse, APRN, PA, pharmacist, or pharmacy technician.
5/16/19

12. The Joint Commission(JCAHO)(2008)
Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking.
This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Transitions in care include changes in setting, service, practitioner, or level of care.
This process comprises five steps:
(1) develop a list of current medications;
(2) develop a list of medications to be prescribed;
(3) compare the medications on the two lists;
(4) make clinical decisions based on the comparison;
and (5) communicate the new list to appropriate caregivers and to the patient
From: Chapter 38, Medication Reconciliation
Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
Hughes RG, editor.
Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.
Copyright Notice
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
The Joint Commission(JCAHO)(2008)
5/16/19

13. The medication reconciliation MUST:
Include the name or other unique identifier of the eligible professional performing the medication reconciliation
Include the date of the reconciliation;
Address ALL known home medications (prescriptions, over-the-counters, herbals, vitamin/mineral/dietary (nutritional) supplements, and medical marijuana)
Address for EACH home medication:
Medication name, indication, dosage, frequency, route, discontinuation date (if applicable), reason for administration, start and end date (if applicable),
If medication was stopped or discontinued
Identification of individual who authorized stoppage or discontinuation of medication
List any allergies, intolerances, or adverse drug events experienced by the patient.
Project Name: Patient Safety
Measure #: NQF 2988.
Pg 7
5/16/19

14. V506: Immunization History, and Medication History
“Medication History” should include a review of patient allergies and all medications including over-the-counter medications and supplements the patient is taking.
The assessment should demonstrate that all current medications for possible adverse effects/interactions and continued need.
Considered part of the Multidisciplinary Care Plan
Based on the NQF 2988 Recommendations
Based on the NQF 2988 Recommendations
5/16/19

15. So how do we start?
5/16/19

16. Evaluation for Potential Medication Record Discrepancies and Medication Related Problems
Examples of Medication Discrepencies
Examples of Medication Related Problems
Pt made change in medication without knowledge of health care team
Change made by member health care team but not recorded into medication record
Omission( taken by patient but not in record)
Commission (no longer being taken by patient but still on med list
Wrong dose
Wrong drug
Wrong frequency
Dose/schedule not listed
Drug without indication
Indication without drug
Wrong drug
Dose to low
Dose to high
Adverse drug reaction
Inappropriate adherence
Drug-drug; drug-disease; drug-food, and or drug-laboratory interaction
Patricia,N.& Foote, E.(2016). A pharmacy based medication reconciliation and review program in hemodialysis patients: A prospective study. Pharmacy Practice 14(3):785. doi: /PharmPract
5/16/19

17. Different Ways to Evaluate Medications
Medication Reconciliation
Medication Review
In depth analysis of medication regimen that includes assessing appropriateness of therapy, dosing, monitoring for efficacy and side effects.
Involves potential interventions to both maximize drug effectiveness and minimize adverse drug reactions.
Process of confirming the accuracy of the medical record. Usually done with the patient or caregiver and should occur at regular intervals.
The accuracy of this record is pivotal.
It is important to make sure it reflects what the patient is actually taking.
Notation of medications not being taken as ordered is equally important.
Patricia,N.& Foote, E.(2016). A pharmacy based medication reconciliation and review program in hemodialysis patients: A prospective study. Pharmacy Practice 14(3):785. doi: /PharmPract
5/16/19

18. Consider using the “Right” Approach to MedRec
This plan is based on the “Rights of Medication” we all learned in nursing school.
Whether you do a Reconcilitation or a Review will depend on what your patients needs at that time.
5/16/19

19. Medication Reconciliation Medication Review
Rights of Med Rec
Medication Reconciliation
Medication Review
Right Person/Patient
Verify
Review all allergies listed, update as needed
Review type of allergic reaction and document.
Right Medication
Check Label
Verify Contents
Evaluate for other names or duplicates
Allergies/Adverse Reactions
Right Dose
Write dose on bottle or other documentation
Verify dose is correct for CKD/ESRD
Right Time
Record when being taken
Note if this is different then prescribed.
Determine if timing of medication is appropriate
Determine why not taking as ordered
Right Route
Record as ordered
Record as being taken
Determine if route is appropriate
5/16/19

20. Medication Reconciliation Medication Review
Rights of MedRec
Medication Reconciliation
Medication Review
Right Reason
Note Diagnosis associated with medication
Does the medication correlate with the listed diagnosis.
Verify Reason for use
Right Response/Outcome
Is it working.
Pain Scales
Infection improving
Are we seeing the expected response?
Have we reached/maintained adequate blood levels?
Do they still need it? Do they feel better? If not why?
Right Prescriber or source
Record name of prescribing LIP or other possible sources
Discharge summary, Nursing home ,ED, Clinic, PCP, cardiology, transplant
Evaluate prescriber information Determine need for continuity of treatment
Ongoing antibiotics
Anticoagulation protocols
5/16/19

21. Medication Reconciliation Medication Review
Rights of MedRec
Medication Reconciliation
Medication Review
Right Information Source
Is the patient /family reliable
Do you have the actual pill bottles?
How do recent Discharge summaries or medical records correlate to patient/family history?
Right List
What does the last MedRec say?
How long ago was it done?
Has anything happened since then that would cause changes?
Hospitalizations
Injuries
Change in place of residence
Right Documentation
Update and document current medications being taken. Note differences in what has been prescribed and what is being taken.
Notify LIP of discrepencies.
Share list with all Care Providers
This should be done monthly. With Date and signature of person doing the MedRec.
Review medications no longer being taken – determine if further action needs to be taken
Communicate as needed with LIP who ordered medication.
Document education and other attempts to remove barriers as needed.
Document in Care Plans – include dates done and providers involved.
5/16/19

22. *Novolog 4 units SC with meals *Bystolic 5 mg PO OD
Medication Concerns
Current Medications
Dose Glipizide (Glucotrol) CrCl<50- decrease dose 50%. This patient is also on 2 different insulin's. ? Evidence of hypoglycemia?
Bystolic (nebivolol) – typical CKD dosing is 2.5 mg OD.
Coreg (carvedilol) and Bystolic are both beta blockers- do we really need both? Does his patient have hypotension?
Benicar is not recommended in CKD, this is also a maximum dose in CKD. Consider other BP med? It greatly impacted with volume depletion. It is an ARB
Crestor –this is max dose. ? S&S Myalgia
Keppra- Extra dose with HD? Evidence of Seizure?
Nepro- What is the albumin level?
No multivitamin?
Plavix/ASA- Adjust heparin ??
*Glipizide 10 mg PO OD
*Lantus 10 Units SQ daily
*Novolog 4 units SC with meals
*Bystolic 5 mg PO OD
*Coreg 6.25 mg PO BID
Diltiazem 30 mg PO OD
*Benicar (Olmesartan medoxomil) mg PO OD
*Crestor 10 mg OP q HS
*Keppra 500 mg PO BID
*Nepro 8 oz PO BID
*Plavix 75 mg PO OD
*ASA 81 mg PO OD
What illness do you think this patient has? DM
Hypertension
Heart Disease
Hyperlipidemia
Seizure disorder
Protein malnutrition
5/16/19

23. Current Medication
Medication concerns
Timing of administration – no faster than 1 gm/ hr and given typically last hour of treatment
Drug levels(trough)
What is the goal – level
PNA, bacteremia, osteomyellitits, meningitis
10-15 – other infections
Blood cultures
Done before dose and review results and determine if correct antibiotic
Vancomycin 750 mg IV on HD x 4 doses
Dx Bacteremia
What Illness/problem do you think this patient has?
infection of some kind
5/16/19

24. Medication concerns Current Medications Pain management- Hypotension
Gabapentin often used for diabetic neuropathy. In CKD Maximum dose is 300 a day
(Dose decreased to 100 mg TID)
Taking two narcotics for pain
Taking high dose of Midodrine – normal dose starts 2.5mg in CKD
Use with caution with Floricef
Dose of Midodrine was reduced 5 mg TID
Florcief was d/ced
Synthroid-
Suggested evaluation of thyroid function
Synthyoid dose was increased to 50 mcg daily.
Interestingly once this was increased
her hypotension improved
Reduction of pill burden is always important
Niferex was discontinued
we manage Fe in the HD unit
Antibiotic dosing is based on longer intradialytic interval
Current Medications
Insulin Sliding scale
Gabapentin (Neurotin) 300 mg TID PO
Midodrine (Proamatine) 15 mg po TID
Synthroid (levothyroxine) 25 mcg PO OD
Fludrocortisone (Floricef) 0.1 mg PO OD
Tramadol (Ultram) 25 mg PO PRN Q 4 hrs
Oxycodone 5 mg PO PRN q 6 hrs
Prosourse 30 ml PO BID
Niferex 150 mg PO OD
Daptomycin 300 mg IV with HD 2x week
Daptomycin 450 mg IV with HD 1 x week
What Illness/problem do you think this patient has?
-DM -Hypothyroid disease
-Infection of some sort
-Pain
-Nutritional issues
-Hypotenison
Side effect gabapentin
Serious
Anaphalaxis
Withdrawal seizures
Rhabdomyolysis
Angio edema
Sucidialty
Erythema multiforme
depression
Common
Dizziness somnolence
Ataxia
Fatigue
Fever
Peripheral edema
Nystagmus
Nausea/vomiting
Tremor
Dipolpia’
Asthenia (generalized weakness)
Diarrhea
Headache
Infection’
Xerostomia (Dry mouth)
Amblyopia (lazy eye)
Constipation
Abnormal thinking
Amenesia
Back pain
Depression
Impotence
Max dose Tramadol 200 mg OD cr/cl<30 – do not use extended release form
5/16/19

25. Promethazine 1 teaspoon PO tid (Phenergan) Santyl per protocol daily
Current Medications
Medication Concerns
SE Include: sedation.dizziness, seizures, electrolyte abnormaltines
Is this a good choice
Does this patient have a wound? Where?
Concern for bacteremia?
Recommendations exist for dose decrease to 10 mg OD
SE myalgia
Both of these anti hypertensive drug are potent vasodilator- does that sound like something we want before dialysis?
Clonidine max daily dosage in 2.4 mg.day- how often do we give additional doses in dialysis
This is very short acting- again do we want it right before HD?
Promethazine 1 teaspoon PO tid (Phenergan)
Santyl per protocol daily
Atrovastatin (Lipitor) 40 mg PO Q HS
Minoxidil 5 mg PO BID
Hydrazaline (Apresoline) 100 mg PO TID
Clonidine 0.3 mg PO TID
What Condidtions does this patient have
?? Allergies/motion sickness/ nausea/vomiting/itching ?
Wound somewhere
Hyperlipidemia
Hypertension
5/16/19

26. Humalog 100 ml SQ Sliding Scale Sildenafil (Viagra) 100 mg PO OD
Current Medications
Medications Concerns
Humalog 100 ml SQ Sliding Scale
Sildenafil (Viagra) 100 mg PO OD
Nicotine Patch 1 Patch daily
Ipratropium bromide (atrovent) 1 packet inhale PRN
Gabapentin 300 mg PO BID
Humalog is dosed 100unit/ml
See any problem here?
Sildenafil
Besides being a vasodilator
Starting dose in CKD/ESRD is 25 mg – also reduced in elderly
He may be taking for Pulmonary Hypertension
Dose would still start lower
Nicotine Patch and Inhalers
Need I say more
Patch strengths vary greatly
Atovent is inhaled using a nebulizer
If should be dosed Q6hrs
Gabapentin Dose is twice what is recommended
What conditions does this patient have
IDDM
Cigarette smoker with COPD?
This guy was admitted from home with Change in Mental Status and Hypotension
Do you think there could be a reason here?
5/16/19

27. Reglan (metoclopramide) 5 gm PO QD Heparin 5000 units SQ q 8hrs
Current Medications
Medication Concerns
Reglan (metoclopramide) 5 gm PO QD
Heparin 5000 units SQ q 8hrs
Reglan dosing is 5-10 mg
And CKD dosing usually starts at 50% of that
This is an outpatient
What do you think the chances they are getting SC heparin?
5/16/19

28. High Risk Medication Vitamin K Antagonists (Coumadin)
Polypharmacy influences the quality of anticoagulation therapy and translates into increased risk of adverse events.
It has been shown to be an independent risk factor of bleeding, hospitalization, and all cause mortality.
(Eggwbrecht,et al, 2019)
5/16/19

29. Medication compliance of hemodialysis patients and factors contributing to non-compliance
Background
Findings:
Data gathered from 75 dialysis patients
1/3 patients did not takes medications as prescribed
Reasons cited:
Forgetfulness- most common reason
Inconvenience or scheduling problems
Only 11% reported money as a reason
Higher education and white race showed greater understanding on need to take medications as prescribed
There was not difference in actual compliance between the groups.
Purpose: determine what factors contributed to medication non-compliance. Looking at variables of age,sex,race and educational level.
Definition of Medication Compliance: The extent to which actual drug taking behavior matches the prescribed regimen.
Potential for problem: USRDS reports patients take an average of between medications daily
Bland,R., Cottrell,R.,& Guyler,L.(2008) Medication compliance of hemodialysis patients and factors contributing to non-compliance. Dialysis and Transplantation. 37(5): Accessed 4/23/19 at
5/16/19

30. Medscape Medical News:May 10,2019
Americans filled a record 5.8 billion prescriptions in 2018
A rate of 17.6 prescriptions per person, up 2.7% over 2017.
One notable exception, though: Opioid prescriptions went down sharply.
More than two thirds of prescriptions filled in 2018 were for common chronic conditions, such as diabetes and hypertension.
These prescriptions were increasingly filled with a 90-day supply through mail order with automatic refills.
With rebates, discounts, and other price concessions, net spending on all US medicines increased 4.5% to $344 billion up from $324 billion in 2017).
The report projects a modest overall increase of 3% to 6% in net spending on drugs in the next 5 years.
5/16/19

31. Medscape Medical News:May 10,2019
Specialty Medicines Prescriptions Rise
Prescriptions for specialty medicines for chronic, complex, or rare diseases grew by more than 5% in 2018, yet accounted for only 2.2% of all prescriptions.
In total, 127 million specialty prescriptions were dispensed in 2018, up by 15 million since 2014.
Prescriptions for antihypertensive drugs grew by 46 million over 2017.
Prescriptions for antihypertensives, lipid regulators, diabetes drugs, anticoagulants, and drugs for mental health all increased by more than 4%
Medscape Medical News © 2019 
Cite this: US Prescriptions Hit New High in 2018, but Opioid Scripts Dip - Medscape - May 10, 2019.
Americans filled a record 5.8 billion prescriptions in 2018 — at a rate of 17.6 prescriptions per person — up 2.7% over 2017, according to a report released Thursday. One notable exception, though: Opioid prescriptions went down sharply.
"The very big picture is that more Americans took more prescription medicines than ever in 2018," IQVIA Executive Director Murray Aitken said on a call with reporters.
However, the volume of prescribed opioids continued to decline steeply in Changes in regulations and clinical guidelines, coupled with increased public awareness, drove a 17% decline in total morphine milligram equivalents (MMEs) dispensed, representing 29.2 billion fewer MMEs. This marks the largest single-year drop ever recorded, down 43% since the peak in 2011.
The report, Medicine Use and Spending in the U.S.: A Review of 2018 and Outlook to 2023, was prepared by the IQVIA Institute for Human Data Science.
Most Meds for Common Chronic Diseases
More than two thirds of prescriptions filled in 2018 were for common chronic conditions, such as diabetes and hypertension.
These prescriptions were increasingly filled with a 90-day supply through mail order with automatic refills, a fact that speaks to the growing focus on patient adherence, Aitken said.
Prescriptions for antihypertensive drugs grew by 46 million over 2017, owing to the aging population and the Association/American College of Cardiology 2017 hypertension guidelines, which reduced the diagnostic threshold for the disorder, according to an IQVIA news release.
Prescriptions for antihypertensives, lipid regulators, diabetes drugs, anticoagulants, and drugs for mental health all increased by more than 4% over 2017, according to the report.
5/16/19

32. Medscape Medical News: May 10,2019
Out-of-Pocket Costs Climb, but Coupons Helping
Total overall out-of-pocket costs reached $61 billion in 2018, up from $56 billion in 2014,
Some patients have seen their costs decline as generic prescription costs have declined,
Coupons for commercially insured patients have reached an all-time high of $13 billion in 2018
more than double the $6 billion coupon offset in 2014 — helping lower commercially insured patients' out-of-pocket costs over the period.
Total Spending on Medicine Continues to Increase
Total net spending on medicines is expected to be between $405 and $435 billion in 2023.
The largest driver of this growth will be the launch of new brands, which are forecast to contribute $73 billion in new spending.
Clinical development across the pharmaceutical industry will result in new drug approvals and uptake.
The report forecasts an average of 54 new medicines launching per year during the next 5 years.
Medscape Medical News © 2019 
Cite this: US Prescriptions Hit New High in 2018, but Opioid Scripts Dip - Medscape - May 10, 2019.
5/16/19

33. With this exponential increase in medications use there is no reason to expect Medication Reconciliation and Reviews will ever go away.
If anything they will become increasingly important component of patient Safety.
It will remain an area that requires ongoing vigilance for accuracy.
As well a ongoing research to evaluate best practice and potential value of electronic systems.
In the end it all comes down to consistent communication with your patient and their various care providers.
5/16/19

34. 5/16/19

35. Happy Nurses Week
5/16/19

36. References
Barnsteiner, J.(2018). Medication reconciliation, Chapter 38. In Hughes R.(Ed.) Patient safety and quality: Evidence-based handbook for nurses. Rockville, MD: Agency for healthcare research and quality.
CMS- Medical learning network presentation (MLN) by Poyer,J.& Houseal,D .(2018). Calendar year (CY) 2019) ESRD prospective payment systems (PPS) proposed rule: ESRD quality incentive program (ESRD QIP) proposal.
Eggebrecht,L.,Nagler,M., Gobel,S., Lamparter,H., Keller,K., Wagner,B., Panova-Neova,M., ten Cart,V., Bickel,C., Lautenbauch,M., Espinol-Klein, C., Hardt,R., Munzel,T., Prochaska,J.,& Wild,P.(2019 Relevance of polypharmacy for clinical outcomes in patients receiving vitamin K antogonists. Journal of American Geriatric Society. 67(3): Accessed on 4/26/19
Bland,R., Cottrell,R.,& Guyler,L.(2008) Medication compliance of hemodialysis patients and factors contributing to non-compliance. Dialysis and Transplantation. 37(5): Accessed 4/23/19 at
Patricia,N.& Foote, E.(2016). A pharmacy based medication reconciliation and review program in hemodialysis patients: A prospective study. Pharmacy Practice 14(3):785. doi: /PharmPract
Steward, C. (2013). Coordinating care for patients needing renal replacement therapies. Care Management. June/ July (3):
Ward,S., Roberts,J.,Resch,W. & Thomas,C.(2016). When to adjust the dosing of pyschotropics in patients with renal impairment. Current Psychiatry. (15)8:
Nagler,E., Webster,A., Vanholder,R. &Zoccalli,C.( 2012). Antidepressants for depression in stage 3-5 chronic kidney disease: A systemic review of pharmacokinetics, efficacy and safety with recommendations by europeannrenal best practice (ERBP). Nephrology Dialysis Transplantation 1:1-10. doi:10.193/ndt/gfs295.
Hess.C.,Linnebur,S.,Rhyne,D. & Valdez,C.(2016). Over-the-counter drugs to avoid in older adults with kidney impairment. Nephrology Nursing Journal.43(5):
Inrig,J.( 2010). Antihyptensive agents in hemodialysis patients: A current perspective. Seminars in Dialysis. 23(3): doi: /j X x
Harisingani,R., Saad,M.& Cassagnol,M.(2013) How to manage pain in patients with renal insufficiency or ESRD? The Hospitalist 2013(8).
Munar,M. & Singh,H.(2007). Drug dosing adjustments in patients with chronic kidney disease. American Academy of Family Physicians accessed 5/7/19 at
National Quality Forum (NQF). Patient Safety Medication reconciliation for patients receiving care at dialysis facilities. Accessed
5/16/19

37. 5/16/19

38. 5/16/19

39.  Send updated medication lists to dialysis facilities.
 Communicate any changes in cardiac function (eg, ejection fraction, cardiac/surgical procedures) to the dialysis unit at discharge.
 Ensure that patients continue mineral bone density (MBD) treatment whenever hospitalized.
 Communicate about any and all medication changes to all who are caring for the patient when discharged (including family members).
 Send updated medication lists to dialysis facilities.
 Ensure that patient and family education about medication use is completed and understanding is apparent.
 Ensure that written prescriptions for all medications are given to patients and families
5/16/19

40.  Begin nutritional consultation early, and start supplements.
 If indicated, obtain a swallowing evaluation.
 Evaluate the patient’s ability to obtain and afford medications after discharge.
 Communicate with the outpatient unit about the continued need for antibiotics.
 Schedule a follow-up visit with the infectious disease specialist or surgeon.
 Notify the dialysis unit notified about follow-up appointments
5/16/19

41.  Continue renal vitamins and supplement iron as needed.
 Ensure continuation of erythropoiesis-stimulating agents (ESA) during hospitalization.
 Continue renal vitamins and supplement iron as needed.
 Evaluate/treat for underlying problems with blood loss including GI loses and anticoagulation. (Note: Postsurgical patients are at especially high risk.)
 Evaluate physical functioning and need for rehabilitation prior to discharge.
 Carefully explain dosing guidelines to the patient and family and the outpatient dialysis facility.
 Communicate any change in “dry weight” to the dialysis center at discharge.
5/16/19

42.  Initiate a Save the Vein program at your institution.
 Notify the dialysis unit of wounds or other open areas that need evaluation.
 Discuss the potential need for isolation requirements with the outpatient facility.
 Initiate a Save the Vein program at your institution.
 Ensure that procedures for facilitating evaluation for permanent access by a vascular surgeon are completed before discharge from the hospital.
 Educate the patient and family regarding catheter/AV access care before discharge.
5/16/19

43. How
5/16/19