36C24419R0074-014.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 11-17 July 9, 2018

MEDICATION RECONCILIATION

I. PURPOSE: The purpose of the Medication Reconciliation process seeks to maintain and communicate accurate patient medication information. It entails identifying, addressing, and documenting medication discrepancies found in the VA electronic medical record as compared with the medication information supplied by the patient.

This information, along with any changes made during the episode of care, is communicated to the patient, caregiver or family member, and appropriate members of the health care team.

Patients are at high risk for harm from adverse drug events when communication about medications is not clear. Many of these events occur at transitions in levels of care or as a result of clinical management by multiple independent health care providers. The chance for communication errors increases whenever individuals involved in a patient’s care change. Communicating about the medication list, making sure it is accurate, and reconciling any discrepancies whenever new medications are ordered or current medications are adjusted, is essential to reducing the risk of transition-related adverse drug events. This policy defines the process and guidance for accurate and complete reconciliation of medications across the continuum of care for the medical center including inpatient (acute care and community living centers), outpatient and home care at all Erie locations. Whenever possible, this process will begin on admission or entry to a service or program and will be ongoing throughout the time that care is provided.

DEFINITIONS:

Medication Reconciliation: Medication Reconciliation is a process to ensure maintenance of accurate, safe, effective, and above all, patient centered medication information by:

a) Obtaining medication information from the patient, caregiver, or family members.

b) Comparing the information obtained from the patient, caregiver, or family member to the medication information available in the VA electronic medical record, including active medications, recently expired medications, medications given at other VA facilities (via remote data view), and non-VA medications, in order to identify and address discrepancies.

Attachment L

MCM 11-17, Medication Reconciliation

c) Assembling and documenting the medication information in the VA electronic medical record.

d) Communicating with and providing education to the patient, caregiver, or family members regarding updated medication information.

e) Communicating relevant medication information to and between the appropriate members of the VA and non-VA health care team.

Local VA Medications: Local VA medications are medications ordered at the treating VA facility.

Non-VA Medications: Non-VA medications are non-VA provider prescribed medications filled at non-VA pharmacies; VA provider prescribed medications filled at non-VA pharmacies, herbals, over-the counter-medications, vaccines, vitamins, nutraceuticals, and alternative medications.

Remote Medications: Remote VA medications means medications ordered at any other VA facilities (viewed or imported via remote data view).

Medication Discrepancy: Medication discrepancies are unintentional differences found in the patient’s medication information when compared to the medication information available on the electronic health record. These discrepancies may be omissions, commissions, inappropriate duplications, changes, and/or additions.

These discrepancies may be generated from the patient or the health care system.

Veterans Receiving Dual Care: Veterans receiving dual care refers to Veterans who receive ongoing health care in both VA and non-VA health care settings.

VA Providers: VA providers are physicians, medical trainees, advanced practice nurses, physician assistants, and other health care professionals who provide primary care or specialty care within the limitations of their individual VA privileges or scopes of practice.

Non-VA Providers: Non-VA providers are community providers including physicians, advanced practice nurses, physician assistants, and other health care professionals who provide health care to Veterans outside of VA. This includes services reimbursed by Non-VA Medical Care, Department of Defense, Tri-Care, Medicare, private pay, and health insurance. Methods to communicate with non- VA providers include phone conversations, FAX, and correspondence by mail after compliance with patient privacy regulations.

II. POLICY:

A. Patient, caregiver, or family member-provided medication information obtained at the episode of care is represented in the VA electronic medical record.

B. A complete and current list of the patient’s medications is obtained and documented: (1) whenever a patient enters the system; (2) transfers within the hospital or outside the hospital; (3) when the patient leaves the hospital’s care or at the end of an outpatient encounter.

C. The medication reconciliation process compares a patient’s best known list of current VA and non-VA medications against information available in the VA electronic medical record. Discrepancies are brought to the attention of the provider and, if applicable, changes are made to the orders.

D. At the end of the episode of care, written information is provided to the patient and/or patient’s family about the medications he or she should be taking, how to take the medications, maintaining a complete and accurate medication list and the importance of communicating the medication list to the next provider of care.

E. Updated medication information at the end of the episode of care is represented in the VA electronic medical record (including changes relevant to the episode of care).

III. RESPONSIBILITY:

A. The Chief of Staff is responsible for ensuring that:

1. VA providers are knowledgeable about their lead role and responsibilities with respect to Medication Reconciliation.

2. VA providers are adequately trained and educated on the Medication

Reconciliation process and understand its importance in the scope of quality patient care and patient safety.

3. VA providers have been provided sufficient resources for inter-provider, inter-departmental, inter-facility, and inter-system communication which conforms to all relevant VA and VHA privacy policies and Federal law.

B. Associate Director, Patient Care Services will assure that the nursing staff is aware of the policy and procedures for medication reconciliation.

C. Pharmacy Supervisor will assure that the pharmacy staff is aware of the policy and procedures for medication reconciliation.

D. Facility Medication Reconciliation Point of Contact (POC) is the Patient Safety

Specialist who is responsible for receiving information and helping disseminate new knowledge of Medication Reconciliation from the Veterans Integrated Service Network (VISN).

E. The Medical Executive Council and the Pharmacy and Therapeutics Committee will review, evaluate, and initiate corrective actions regarding medication reconciliation based on compliance monitoring data; and/or additional guidance received from VHA and/or the Joint Commission.

F. VA Provider is responsible for:

1. Completing Medication Reconciliation including medications prescribed by, or secured outside of, the VA system to diminish the potential safety risk for the dual care patient. (Refer to VHA National Dual Care Policy 2009-038).

2. Documenting a plan to address medication discrepancies that is commensurate with the severity of the discrepancy and the risk of patient harm. NOTE: Addressing a discrepancy does not always require managing a medication or changing the medication order.

3. Educating patients identified as dual care users as per VHA National Dual

Care Policy 2009-038.

4. Documenting and reporting adverse events and close calls reporting.

Adverse drug events must be entered in CPRS and the VA Adverse Drug Event Reporting and Monitoring System (ADERS).

5. Assisting the Veteran patient, caregiver, or family member to maintain, update, and take ownership of, the patient's medication information.

Patients need to be encouraged to be active participants in the decision making of their treatment plan.

IV. PROCEDURES:

A. The health care team includes providers, nurses, pharmacists and other interdisciplinary team members who are responsible for the following:

1. Medication Reconciliation is initiated at every episode or transition in level of care where medications will be administered, prescribed, modified, or may influence the care given.

2. Admission (applies to inpatients):

a. Upon admission, a list of medications the patient is currently taking is obtained and documented in the Computerized Patient Record System (CPRS) by the admitting VA provider. The medication information is often obtained from the patient but other sources may include the patient’s family, significant other, nursing home, local pharmacy, past discharge summary, and/or clinic visit notes.

b. Use the list already documented in the patient’s medical record to prompt the patient or their source regarding their medications.

Remove from the active medication list any medications that are not current for the patient.

c. The following information should be documented in the medical record when known and provided by the patient or his/her source:

dose, route, frequency, and purpose of VA and non-VA medications, over-the-counter (OTC) drugs, herbal/alternative medicine products, and any other product designated by the FDA as a drug. The inpatient process should be completed within 24 hours.

d. The VA provider compares the medication information the patient is currently taking with the medications ordered for the patient to identify and resolve discrepancies.

e. The clinical staff; e.g. nursing, pharmacists, therapists, will communicate medication discrepancies or questions noted by the patient or clinical staff to the treating provider, i.e., physician, nurse practitioner, or physician assistant, in order to avoid adverse medication events.

f. The VA provider will review and act upon each medication, ordering those that are appropriate for the patient’s current condition.

g. All medication orders will then be reviewed by a pharmacist and compared to the home medication list, and processed according to policy.

3. Transfers:

a. When the patient is transferred to another level of care or service, an open channel of communication must exist to ensure a complete list of medications is transferred to the new provider and/or nursing staff. For VA inpatients transferred within the VA system, the patient’s medication administration record in CPRS is available to all of the patient’s care providers. The admitting VA provider completes the medication reconciliation process.

b. When the patient is transferred to a non-VA facility, the list is communicated by the VA Provider via the Inter-facility Transfer Note.

4. Discharges:

a. At discharge or at the end of an outpatient encounter, the patient’s reconciled list of admission medications is compared against the inpatient and outpatient lists to determine clinically appropriate discharge medications. The provider makes changes as appropriate for the patient’s clinical status.

b. At discharge or at the end of an outpatient encounter, patients are provided a complete written list of the medications they are to take following discharge. *Exception: In non-24-hour settings when the only additional medications ordered are for a short duration, the medication information provided includes only those medications (Urgent Care Center, Outpatient Radiology, Behavioral Health, Ambulatory Surgery, Primary Care, and Diagnostic Settings).

c. The patient/caregiver receives education or instructions on the medications to be taken after discharge in a manner the patient/caregiver can understand. The patient/caregiver is instructed to share the medication list with their next provider, contact their provider with any medication changes, (for example, when medications are added, discontinued, or doses are changed), and to carry the medication information they receive at all times in the event of an emergency.

5. Non-24 Hour Settings:

a. Medication reconciliation should occur any time changes are made to current medications, or when a new medication is ordered.

b. Non-24-hour settings include the Urgent Care Center, Outpatient

Radiology, Behavioral Health, Ambulatory Surgery, Primary Care and Diagnostics Setting.

c. In these settings, obtaining the name(s) of the patient’s original, known and current medications that he or she is taking at home is required.

d. If new chronic medications are ordered or adjusted, the patient will be provided with a new list of medications at the end of the episode of care.

e. When only short-term medications (e.g. short-term course of antibiotic) will be prescribed and no changes are made to the patient’s current medication list, the patient and/or patient’s family, are provided with a list containing only the short-term medication additions that the patient will continue after leaving the facility.

6. Outpatients/Behavioral Health Setting:

a. At all clinic visits where medication management is the focus, the VA provider will obtain a current list of medications from the patient or family. If the patient does not bring a medication list to the visit, the medication list in CPRS will be printed and reviewed with the patient for accuracy prior to ordering of any medications.

b. The patient will review the list and communicate to the VA provider any changes in the medication, dosage or frequency. The VA provider will enter any changes in the pharmacy package so an accurate medication list is in the medical record.

c. Discrepancies between the list and what the patient should be taking should be referred to the patient’s primary care provider or provider responsible for the medication.

d. The VA provider in the short-term setting will review the list before ordering any setting-specific medications and assess for potential medication adverse events that might occur because of duplication, drug and food interactions, allergic reactions, etc. and document in the progress note.

e. If new chronic medications are ordered or adjusted, the patient will be provided with a new list of medications at the end of the outpatient visit. When only short-term medications (e.g. short-term course of antibiotic) will be prescribed and no changes are made to the patient’s current medication list, the patient and, as needed, their families are provided with a list containing the short-term medication additions that the patient will continue after leaving the facility.

7. Urgent Care Center:

a. A complete and accurate medication history based on the information available at the point of care is obtained for each patient and documented in CPRS. The patient will be asked to verify the medication list in CPRS or supply a current list of medications.

b. The patient’s list of medications should be obtained as soon as possible during the patient’s encounter, after the management of emergent situations which may prohibit the ability to gather this information.

c. The medication information to be collected requires only the drug name.

d. The triage nurse will obtain medication list and forward to the

UCC physician who will review the list for discrepancies.

e. If new chronic medications are ordered, a written list will be provided for the patient at the time the patient leaves the department.

f. At discharge, when only short-duration medications are prescribed, the patient is provided with a written list containing only the short-term medication additions that the patient will continue after leaving the hospital.

g. If the patient is transferred to a non-VA facility, a list of the patient’s current medications will be sent with the patient via the Inter-Facility Transfer Note. If the patient is admitted to the VA, the admitting provider will perform the medication reconciliation.

8. Radiology: For all procedures requiring contrast, it will be documented that a patient’s medication list is on the chart. If contrast is being given, the radiological technician with competency will review the allergy list and compare it to the contrast being given. Questions or concerns will be referred to the pharmacist or the radiologist.

9. Perioperative Setting:

a. For outpatients, the patient will be asked to supply a current list of medications or review and verify the list in CPRS. For inpatients, the medication list in CPRS shall be used as the current medication list.

b. If the initial review of medications is completed before the procedure date, the patient will be asked on the day of the procedure or surgery if there have been any changes in his/her medications. The provider performing the procedure or surgery should be notified of any changes. Changes should be documented in the patient’s electronic medical record.

c. The medication list is reviewed and reconciled by the provider before any new medications are administered and/or prescribed.

d. After the procedure, the medication list prior to the procedure and the post-operative medication orders are reviewed by the VA provider. Discrepancies between the list and what the patient should be taking should be referred to the patient’s primary care provider or provider responsible for the medication.

e. If new chronic medications are ordered after the procedure, a written list will be provided to the patient at the time the patient leaves the department.

f. When the only additional medications ordered are for a short duration, the medication information provided to the patient includes only those medications.

10. Home Based Primary Care:

a. Upon acceptance into the Home Based Primary Care Program (HBPC), the Registered Nurse will take to the home the most recent and active medication list which includes VA and non-VA medications and reconciles them with the patient and/or family.

b. Medications taken but not included on the list are brought back to the attention of the pharmacist and provider for review and necessary addition to the medication list in CPRS and or prescription.

c. The most recent and active medication list is taken to the home on each registered nurse visit with reconciliation occurring at that time.

11. If the patient wishes to have the discharge medication list sent to a non-VA provider, a list will be generated and mailed to the provider after appropriate Release of Information procedures.

V. REFERENCES:

A. The Joint Commission Comprehensive Accreditation Manual for Hospitals, Home Care, and Behavioral Health, current editions

B. VHA Handbook 1050.01. VHA National Patient Safety Improvement Handbook, dated March 4, 2011

C. VHA Directive 2011-012, Medication Reconciliation, dated March 9, 2011

D. Medication Reconciliation: Complying with NPSG.03.06.01, The Joint

Commission Perspectives on Patient Safety, March 2011, Volume 11, Issue 3,

pp. 1, 3-5

E. VHA National Dual Care Policy 2009-038, dated August 25, 2009

F. VHA Directive 1164, Essential Medication Information Standards, dated June 26, VI. FOLLOW UP RESPONSIBILITY: The Chief of Staff is responsible for the contents, updates and recertification of the Memorandum

VII. REPORTING REQUIREMENTS: None

VIII. RESCISSION: MCM 11-17, Medication Reconciliation, dated July 23, 2013.

(Original signed 7/9/18) David. C. DiGiacomo, Associate Director On behalf of:

John A. Gennaro Medical Center Director