D.12 MEDICATION RECONCILIATION 36C24423R0132.pdf

Update 3/20/19

Section 32: MEDICATION RECONCILIATION

32.1 PURPOSE

To establish a consistent process for accurately and completely reconciling patient medications for inpatients and outpatients at the Lebanon Veterans Affairs (VA) Medical Center.

32.2 POLICY

The Medication Reconciliation process seeks to maintain and communicate accurate patient medication information across the continuum of care. 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, family, care giver or referring facility. When required, this information, along with any changes made during the episode of care, is documented in the VA electronic medical record and communicated to the patient, caregiver or family member, and appropriate members of the health care team.

32.3 DEFINITIONS

A. Medication – Any product designated by the Food and Drug Administration (FDA) as a drug, which is prescribed by the VA or by other health care providers. Also included are products purchased over the counter (OTC) by the patient, including vitamin products, herbal supplements and alternative medicines.

B. Medication Reconciliation – The process of comparing a patient’s medication documented in the VA electronic medical record to all of the medications that the patient is actually taking at the time of the episode of care. The reconciliation process is done to avoid medication errors such as omissions, duplications, dosing errors, discontinued medications or drug interactions. It should be done at every episode of care or transition in level of care where medications will be administered, prescribed, modified, or may influence the care rendered.

C. Episode of care – A clinical encounter with a VA provider where medications will be administered, prescribed, modified, or may influence the care rendered.

D. Transition in level of care - Admission from the outpatient setting, Admissions from outside facilities, Movement in level of care during a hospital admission (ie:

Transfer from ICU to floor status) change in provider service of care (ie: Medicine service to Surgery service) Discharge to; home, outside facility (VA or Non-VA) or alternative level of care within the Facility (ie: Acute Medicine to Community Living Center).

E. VA Provider – Physicians, Physician Assistants, Advanced Practice Nurses, Podiatrist, Dentist or other health care professionals who provide primary care or specialty care within the limitations of their individual VA privileges or scopes of practice.

F. Discrepancies – Medication changes found in CPRS (the VA electronic medical record) when reconciled to the medication list or information provided by the patient, family, care giver or referring facility. These changes include omissions, duplications, dosing errors or discontinued medications.

G. Hand off communication - When a Medication Reconciliation is required, the reconciled list of medications will be provided to the patient, caregiver or family member or appropriate members of the health care team upon discharge from inpatient or outpatient episode of care. Note: Patients who choose to participate in dual care [co-practice] should be asked about their desire to have medication reconciliation information shared with the dual care Non-VA provider. This information may be sent directly to a patient’s dual care Non-VA provider once the patient completes an ROI (Release of Information) authorization and provides the dual care Non-VA provider's contact information. Similarly, it is sufficient for the VA provider to supply a reconciled medication list to the patient for them to provide to the dual care Non-VA provider when contact information is unavailable, unknown or the patient has chosen to be responsible for providing this information to the dual care Non-VA provider.

H. Specialty providers – Those providers that supply specialty care outside of the primary care requirements including, but not limited to: Behavioral Health, Cardiology, Dental, Dermatology, Endocrinology, ENT, Gastroenterology, Hematology/Oncology, Infectious Disease, Nephrology, Neurology, Ophthalmology, Optometry, Orthopedics, Podiatry, Psychiatry, Pulmonology, Rheumatology, Surgery, Urology

32.4 PROCEDURE

A. Medication Reconciliation is a team effort headed by the patient’s medical provider with support from Pharmacy, Patient Care Services (Nursing), and Health Administrative Services (HAS). Medication reconciliation occurs during an episode of care with communication to the patient, caregiver or family member with hand off communication to additional healthcare providers involved with the patient's care as required.

B. For documentation of Medication Reconciliation, Primary Care Providers will utilize the After-Visit Summary (AVS) provided in CPRS. All other providers may choose to utilize the AVS or the Medication Reconciliation Note provided in CPRS.

C. Outpatient Procedures (Non-24 Hour Settings):

a. The patient will be educated during his initial outpatient visit and returning visits (episodes of care) regarding:

i. The patient is expected to be a responsible partner in his/her health care and is responsible to inform their VA provider of any changes to the medications that they are taking.

ii. The patient should bring a list of medications to all outpatient appointments. The nurse/designee will interview the patient about their current list of medications and note on that list any discrepancies in preparation for the provider’s use.

iii. VA Provider will complete a medication reconciliation as required for each episode of care by:

1. Review the patient’s current list of medications, prior to ordering, changing, discontinuing or administering any medications.

2. Reconcile discrepancies found in the patient’s current list of medication

3. Specialty providers will only reconcile medications related to their specialty.

4. For discrepancies identified for medications not related to the specialty care, a hand off communication will be sent to the Primary Care Provider for review utilizing the Specialty Medication Reconciliation Note.

5. Steps to reconcile discrepancies:

a. Enter changes to the medications listed under the

MEDICATION TAB in CPRS based on the reconciliation

b. Document the reconciled list in the VA electronic record utilizing the appropriate Medication Reconciliation Note template.

c. Educate the patient about revisions to their current list of medications.

d. Educate the patient about the importance of communicating information about their reconciled list of medications to next provider of care. When applicable, inform the patient about the risks of refusing such communication.

e. Provide the patient with a copy of the revised medication reconciliation list. When applicable provide an additional copy for the patient to give to their dual care Non-VA provider.

f. Encounter where only Artificial Tears are prescribed and no discrepancies are found with current medications, will NOT require a medication reconciliation note.

b. Specialty provider encounters, where no medications changes are made, or no discrepancies are found with current medications, will NOT require a medication reconciliation note. Dental encounters where only Fluoride is prescribed will NOT require a Medication Reconciliation note.

c. Emergency Department encounters:

i. Medication Reconciliation with the patient will be performed by nursing at time of intake and documented in the Emergency Department Nursing Medication Review note. This information will be reviewed by the Emergency Department clinical provider.

Medication changes related to the Emergency Department encounter will be reconciled and documented in the Emergency Department Discharge Instructions note. The primary care provider will be designated as a co-signer for this note for Hand off communication

d. ASU (Ambulatory Surgery Unit):

i. Medication Reconciliation will be performed as part of the

MEDICAL PRE-OP EVALUATION episode of care. Medications will be reviewed as part of the SURGERY-DAY OF SURGERY H&P episode of care. For Discharge from the ASU a Medication Reconciliation will be documented in the DISCHARGE INSTRUCTIONS FOR POST-OPERATIVE PATIENTS and

OUTPATIENT DISCHARGE INSTRUCTIONS FOR

COLONOSCOPY/ESOPHAGOGASTRODUODENOSCOPY

(EGD)/SIGMOIDOSCOPY notes.

e. Outpatient Respiratory Therapy Department and Radiology: Procedure done in the Respiratory Therapy Department and Radiology will only be required to review specific medications and allergies that may cause adverse reactions during these procedures. A complete medication reconciliation will NOT be required.

D. Inpatient Procedure:

f. Admission

i. At time of admission to an inpatient level of care a medication reconciliation will be done as part of the admission history and physical by the admitting provider. This will be documented in the Admission medication reconciliation note.

g. Transfer

i. A medication reconciliation will be done at time of transfer from one level of care to another (ie: ICU to floor status) or transfer from one service to another service, within the same level of care (ie:

Medicine service to Surgery service). This will be documented in the Transfer medication reconciliation note.

h. Discharge

i. A medication reconciliation will be done at time of discharge from an inpatient admission. This includes discharge to home, personal care home, alternative level of care within the facility, an outside facility (i.e.: community nursing home, another VA facility or an outside hospital). The medication reconciliation will be documented in the Discharge Instruction- Home or the Discharge Instruction- Alternative Level of Care.

ii. The patient is provided a copy of the discharge instructions which includes the reconciled medication list.

iii. Hand off communication of the discharge instruction with the medication reconciliation is alerted to the VA primary care provider.

iv. If the patient has a Non-VA provider, they will be asked about their desire to have the discharge instructions with medication reconciliation information sent to this provider. This information may be sent directly to a patient’s provider once the patient completes a ROI (Release of Information) authorization and provides Non-VA provider contact information. Similarly, it is sufficient to give a copy of the discharge instructions with medication reconciliation information to the patient for them to provide to the Non-VA provider when contact information is unavailable or unknown or the patient has chosen to be responsible for providing this information to the dual care Non-VA provider.

32.5 RESPONSIBILITIES

A. The Medical Center Director is ultimately responsible for ensuring that the Medication Reconciliation policy is implemented throughout the organization.

B. The Chief of Staff, Chief of Pharmacy, Associate Director for Patient

Care Services (AD/PCS) and Care Line Managers/ACOSs have oversight responsibility for ensuring that clinical staff are in compliance with this policy and procedure.

C. The Care Line Managers/ACOSs and Nurse Managers are responsible for the implementation of the Medication Reconciliation policy within their care lines.

D. VA Providers are the driving force for Medication Reconciliation at the patient level.

E. The Interdisciplinary Treatment Team Members (VA Providers, Pharmacists, Patient Care Services (Nursing), and Health Administrative Services (HAS)) - Under the leadership of the VA Providers share responsibility for implementation of the Medication Reconciliation policy.

32.6 REFERENCES

A. Joint Commission National Patient Safety Goals, April 2010; available at: A http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/.

National Patient Safety Goal on Reconciling Medication Information

(NPSG.3.06.01).

B. Preventing Medication Errors, Committee on Identifying and Preventing Medication Errors, Philip Aspden [et al.], editors, 2006.

C. Adherence to long-term therapies: evidence for action. World Health

Organization 2003.

http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf

D. PBM Web site Standardized Definitions of ADE’s and ADRs:

http://vaww.national.cmop.va.gov/PBM/default.aspx. NOTE: This is an internal VA Web site not available to the public.

E. VHA Handbook 1050.01. VHA National Patient Safety Improvement Handbook.

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf http://vaww.national.cmop.va.gov/PBM/default.aspx

32.7 Reissue Date: May 2022