D.2 11-108 Medication Reconciliation Process.pdf

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

VISN 19

EASTERN OKLAHOMA VA HEALTH CARE SYSTEM MUSKOGEE, OK

MEDICAL CENTER MEMORANDUM 11-108 April 26, 2018

MEDICATION RECONCILIATION

I. PURPOSE: The facility has adopted this policy and procedure with the intention of equipping the Veteran and/or care giver with the medication information needed to prevent adverse events associated with medication and to obtain the desired response to medication as one aspect of managing illnesses, preventing disease, and promoting health.

II. POLICY: It is the policy of the Eastern Oklahoma VA Health Care System clinical staff will demonstrate stewardship for medication reconciliation and information management by providing medication education to the Veteran and/or care giver at all levels of the Veteran’s care. EOVAHCS providers will be held accountable for educating the Veteran and/or care giver on the desired effects and possible side effects of the medication they prescribe.

III. RESPONSIBILITY:

a. Chief of Staff (COS) is responsible for implementation of this policy with all clinical staff to ensure compliance with this and all related Medical Center policies. The COS is further responsible for the following: resolving process deficiencies with service chiefs, ensuring the clinical service chiefs establish a chain of responsibility within their department for medication reconciliation and education, and promoting medication education as a patient safety issue.

b. Associate Director of Patient Care Services (ADPCS) is responsible for ensuring that pharmacy and nursing staff are in compliance with this policy.

c. Clinical Service Chiefs are responsible for ensuring staff compliance with the medication reconciliation process outlined in this policy and resolving deficiencies as soon as they are identified. They will also establish a chain of responsibility within their department for the smooth execution of the medication reconciliation process.

d. Providers at all levels of care (e.g. inpatient, outpatient, surgery, and all specialty clinics) will educate the Veteran and/or care giver on the medication prescribed for the Veteran at the time the medication is ordered. Education will be provided in a manner that the Veteran and/or care giver can understand and documented in the electronic health record. The Veteran and/or care giver will be allowed adequate time to ask questions of the provider and receive answers to their satisfaction. Documentation must include medication that has been discontinued, changed, or is new for the Veteran. The

D.2 11-108 MEDICATION RECONCILIATION PROCESS

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EOVAHCS Medication Reconciliation Policy Medical Center Memorandum 11-108 4/26/2018

Medication Use Reconciliation Clinical reminder should be used to avoid medication errors. Please see Appendix A for example. (If the Veteran is cognitively impaired and no care giver is available, this too must be documented as rationale for why no education was completed. And education or educational materials must be provided to a care giver or the Veteran as soon as feasible.)

(1) Develop a list of current medications.

(2) Develop a list of medications to be prescribed.

(3) Compare medications on the two lists.

(4) Make clinical decisions based on the comparison.

(5) Communicate the new list to appropriate caregivers and the Veteran.

e. Pharmacy will assist the providers in educating the Veteran and/or care giver on all medication desired effects, untoward effects, and other specific information that is pertinent to the Veteran consuming the medication safely and correctly. The Pharmacy will be responsible for providing a complete list of current medication to the Veteran and/or care giver at discharge from the inpatient service, as well as written information on medication effects and side effects. Pharmacy staff will also provide counseling and written information for outpatients as needed.

f. Nursing staff will assist providers in obtaining a complete medication list at the time of admission to an inpatient stay or outpatient visit. It is the nurses’ responsibility to query the Veteran and/or care giver about medication changes since the last visit including over-the-counter (O.T.C.) medication, herbals and supplements the Veteran is currently consuming, as well as medication the Veteran is currently taking that is prescribed by a non-VA provider. Nursing staff will ensure that the VA provider is given this medication information. Nurses will provide medication education when administering medication and document this in the electronic record as well as document the Veteran’s and/or care giver’s understanding of the education.

g. PACT Clinical Pharmacy Specialist will assist providers in obtaining a complete medication list from Veterans being seen by the PACT team for the first time prior to their initial visit. It is the responsibility of the CPS to obtain an up-to-date list of the Veteran’s current prescription medications, OTC medications, herbals and supplements the Veteran is currently consuming as well as any known allergies or significant adverse drug reactions (A.D.R.) the Veteran has experienced. If the Veteran or caregiver cannot provide a medication list prior to the appointment, the CPS will request the Veteran bring a written list or bring their medication bottles to their initial appointment for review with the PACT team at the intake visit. If the Veteran cannot be reached, appropriate documentation of contact attempts will be made in the patient chart. The PACT CPS will also review policies and procedures of the outpatient pharmacy with any Veteran unfamiliar with VA pharmacy processes.

IV. PROCEDURES:

a. Emergency Department (ED) will follow the delineated responsibilities in Section III above. Ancillary staff or nursing staff will print a patient medication list on admission to the Emergency Department for the Veteran and/or care giver to peruse. (Note: Serious emergencies may not allow nursing staff time for medication query or the Veteran may be unable to discuss medication due to the seriousness of the Veteran’s condition. In this instance, any medication reconciliation must be done as accurately as possible by the provider.) The current list will be used by nursing staff to assist with the nursing medication query and the information will be given to the provider when it is as complete as possible. If the provider does not change any medication during the ED visit, the ED staff informs the Veteran and/or care giver then provides the list when the patient is discharged. If medication is changed or the patient is admitted, the pharmacy staff will ensure the patient receives final medication education and the current list of medication the Veteran should be taking. The provider will use the appropriate documentation template for the situation and add any other pertinent facts regarding the medication reconciliation process that were completed.

b. Outpatient Clinics will follow the delineated responsibilities in Section III above.

When the patient comes to the clinic, the Medical Support Assistant (MSA) or the nurse will print the medication list that is currently in the Veteran’s electronic record. The Veteran and/or care giver will be instructed to peruse the list and make note of any additions or changes before they see the provider. During intake, the nurse will query the Veteran and/or care giver of any medication changes, including O.T.C.’s, herbals, supplements, or medication prescribed by a non-VA provider and notify the provider of any not on the current list. During the visit, if changes are made to the Veterans medication, the provider educates the Veteran and/or care giver of any changes and documents what medication has been discontinued, changed, or is new for the Veteran, in the electronic record. The Veteran and/or care giver will be encouraged to go to pharmacy for further education and written medication information. Pharmacy will provide a complete and current list of medication to the Veteran and/or care giver at the time of discharge from the clinic. The provider may choose to use the original list with the changes hand-written on the list, if the medication can be mailed and the Veteran and/or care giver choose not to go to pharmacy for final education and a current list. The provider will use the appropriate documentation template provided for the situation and add any other pertinent facts regarding the medication reconciliation process that were completed. (If the Veteran is cognitively impaired and no care giver is available, this too must be documented as rationale for why no education was completed. And education or educational materials must be provided to a care giver or the Veteran as soon as feasible.)

c. Inpatient Staff will follow the delineated responsibilities in Section III above. When the Veteran is admitted to inpatient service, the inpatient staff must reconcile the Veteran’s medication list again even if the Veteran was admitted through the ED. (This could be the first opportunity to thoroughly discuss the medication list with the Veteran and/or care giver if the Veteran was too unstable in the ED.) On admission, the Medical Support Assistant (MSA) or the nurse will print the medication list that is currently in the Veteran’s electronic record. The nurse will query the Veteran and/or care giver regarding any medication changes, including O.T.C.’s, herbals, supplements, or medication prescribed by a non-VA provider, and notify the attending provider of any not on the current list. During the inpatient stay, if changes are made to the Veteran’s medication, the provider educates the Veteran and/or care giver and documents what medication has been discontinued, changed, or is new for the Veteran. (If the Veteran is cognitively impaired and no care giver is available, this too must be documented as rationale for why no education was completed. And education or educational materials must be provided to a care giver or the Veteran as soon as feasible.) The provider will use the appropriate documentation template provided for the situation and add any other pertinent facts regarding the medication reconciliation process that were completed. Pharmacy will reinforce the provider’s medication education, provide written information on the medication, and provide a complete and current list of medication to the Veteran and/or care giver at the time of discharge.

d. Home Based Primary Care will query the Veteran and/or care giver regarding new O.T.C.’s, herbals, supplements, or medication prescribed by a non-VA provider with each encounter. The provider must educate the Veteran and/or care giver regarding desired effects, untoward effects, and other specific information that is pertinent to the Veteran consuming the medication safely and correctly. The education of the Veteran and/or care giver must be documented in the medical record. The provider will use the appropriate documentation template provided for the situation and add any other pertinent facts regarding the medication reconciliation and the education process that were completed.

e. Behavioral Medicine will follow the delineated responsibilities in Section III above.

Providers will avoid changing the Veteran’s routine medication (prescribed by the Primary Care Provider) during the encounter. However, when new medication is prescribed or current medication is changed or discontinued, the Behavioral Medicine provider must educate the Veteran and/or care giver regarding changes, desired effects, untoward effects, and other specific information that is pertinent to the Veteran consuming the medication safely and correctly. The education of the Veteran and/or care giver will be documented in the medical record. The provider will use the appropriate documentation template provided for the situation (inpatient service or outpatient clinic) and add any other pertinent facts regarding the medication reconciliation process that were completed.

f. Surgery, Surgery Clinics, and Specialty Clinic Providers will avoid changing the Veteran’s routine medication during the encounter. However, when new medication is prescribed, the provider must educate the Veteran and/or care giver regarding desired effects, untoward effects and other specific information that is pertinent to the Veteran consuming the medication safely and correctly. The education of the Veteran and/or care giver must be documented in the medical record. The provider will use the appropriate documentation template provided for the situation and add any other pertinent facts regarding the medication reconciliation process that were completed.

V. REFERENCES:

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

b. The Joint Commission Comprehensive Accreditation Manual for Hospitals

VI. FOLLOW-UP RESPONSIBILITY: Pharmacy Service is responsible for the contents of this MCM.

VII. RESCISSIONS: Medical Center Memorandum 11-108, same subject, dated March 5, 2015.

/s/

MARK E. MORGAN, MHA, FACHE

Medical Center Director

Dist. C

EOCAHCS Medication Reconciliation Appendix A Medical Center Memorandum 11-108