1. The Implementation of Medication Reconciliation in PAC Enhancing Patient Safety The Implementation of Medication Reconciliation in PAC Enhancing Patient Safety Safer Health Care Now ! Medication Reconciliation? Directions for Completion Frequently Asked Questions! Medication History / Admission Order Form Medication History / Admission Order Form Medication History / Admission Order Form Directions for Completion Implementing a Medication History/Admission Order Form 1. How in depth do we become involved to clarify accuracy of medication list when patients are unsure of complete medication list taking? Determining the BPMH requires one to tap into all resources – patient / family interview, community / hospital pharmacy, patient list or vials of medications upon initial admission, lists noted in previous hospital chart. Note: the potential for adverse drug events occurs when we assume the list accompanying the patient is verified for accuracy. Consider any red flags that indicate patient may be prescribed or not prescribed a medication in error. Thoroughly investigate as far as considered necessary to clarify accuracy of current medication list accompanying patient. Remember this step is the most vital in preventing medication errors. PAC Nurses: Ensure all sources required to verify the Best Possible Medication History (BPMH) are indicated upon admission. PAC Nurses: Indicate any illnesses patient has. Physician: post-op checks appropriate boxes indicating if pre-admission medications are for Continue, Change, Hold or Discontinue. Also, indicate reason for Hold, Change or Discontinue. Note: New medications that may be ordered post op are indicated as usual on the pink Physician Order Sheet. If Inpatient RN is in situation of receiving orders by phone the RN checks the appropriate boxes as ordered and signs here as per telephone / verbal order. Later, to be cosigned by physician as per usual policy. Staff member verifying the medication for the BPMH initials appropriate box for each medication verified. Physician: signs here for approval of the boxes that were checked with each medication PAC Nurses: When the BPMH is collected sign indicating so. PAC Nurses: If BPMH collected by more than one RN indicate both signatures. PAC Nurses: List all medications patient taking at home, including OTC and Herbals. Ensure list is as accurate as possible before adding to list. This forms the BPMH-Best Possible Medication History. Thorough medication history taking practices are vital in this step. Please review interviewing techniques (listed on this poster) for important steps to consider. Remember this list will form basis for Admission Orders post-op, after verified with physician. Pre-op Nurses or Inpatient Nurses: If additional regular pre admission / transfer medications are identified after initial BPMH was collected (ie. upon day of admission for surgery or later) indicate here and sign as addition to BPMH. PAC Nurses: After collecting BPMH list indicate Risk Score after completing Risk Tool on back of this form (Tool shown here) Inpatient RN: Following completion of orders the front and back of this form (medication history/orders and completed Risk Tool) is faxed to Pharmacy. 2. Are all medications – OTC, herbal- listed when collecting the Best Possible Medication (BPMH)? List all prescribed, OTC and herbal medications determined to be taken by the patient or physician recommended medications? Once listed the ordering physician decides if the medications listed then should be continued, discontinued, etc upon admission. List all prescribed, OTC and herbal medications determined to be taken by the patient or physician recommended medications? Once listed the ordering physician decides if the medications listed then should be continued, discontinued, etc upon admission. 3. Sometimes patients after initial day of admission report they take additional medications that they forgot to indicate at the time the medication history was collected. Where are these medications then listed and ordered? Such medications are listed in the Additional Medication section so that all pre-admission medications are listed in one area. In addition, the physicians intention to continue, discontinue, hold, change etc. should still be checked in the appropriate adjacent boxes by the nurse after discussion with the physician. However, the physician order for these additional pre-admission medications that are now noted at a later date is to be indicated on the pink Physician Order sheet. This is because usual processes do not trigger a nurse to backtrack and check for orders that may have been documented on a form initiated days before. 4. How can I be sure I have a BPMH? BPMH means obtaining the best possible medication list possible. Ensure you practice good medication history taking techniques. Refer to Tips For Medication History Taking indicated below. Ensure you consider all possible resources (as indicated on Medication History / Admission Order Form) for information that can verify a current accurate medication list. Tips For Medication History Taking A process in which medications are compared at interfaces of care: 3Admission 3Transfer 3Discharge Discrepancies are identified and reconciled with physician Intervention minimizes patient harm from unintended discrepancies ISMP Canada 2005 Note: PAC Nurses do not fax this form to pharmacy on the day the medication history and risk score is completed in PAC Clinic. This is done post-op by inpatient RN who is receiving the patient. Note: This completed form becomes the admission medication history list. Therefore, to reduce duplication and reduce potential for error with multiple lists any other areas where medication history list have been usually written (ie. admission history or nursing kardex) should indicate for pre-admission medications “See Medication History / Admission Orders List” Pre op Nurse: verifies that nothing has changed since medication list taken in PAC. If Yes, note in additional medication section. Pharmacy: If Risk Score indicates, Pharmacy will also assess patients BPMH and indicate any additions or revisions in the Additional Medication section that is related to accuracy of the BPMH. As well, will follow up by communicating to unit nursing staff and / or physician of any recommendations related to the medication regime. The referral process may take up to 48-72 hrs for pharmacy to complete the patient assessment.