D.3 Medication Reconciliation 11-1.pdf

JOHN D. DINGELL VA MEDICAL CENTER 11-1

DETROIT, MI 48201 May 23, 2018

If policies become expired, this medical center considers policies in effect until rescinded or updated by the policy owner.

Policies and procedures cannot possibly address all situations, please make sure that you exercise good judgment and common sense. Remember, patient needs always come first. The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender.

MEDICATION RECONCILIATION

1. PURPOSE

To standardize the process for the development, reconciliation and communication of an accurate medication list throughout the continuum of care.

2. POLICY

Medication reconciliation will occur at each event as defined in this policy. Staff (physicians, RNs, CRNAs, PAs, NPs, RPhs, etc.) will work together along with the patient and/or his/her surrogate to ensure the accuracy of the patient’s medication list. This process actively involves the patient who is responsible for informing health care providers regarding any medications, over the counter (OTC) products and herbals that he/she is or is not taking, dosages, frequency, and routes.

3. DEFINITIONS

(1) Adverse Drug Reaction (ADR). ADR is a response to a drug which is noxious and unintended and which occurs at doses normally used in people for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function. ADRs can be mild, moderate, or serious in nature; likewise, they can be observed or historical.

(2) Brown Bag Inventory. Brown Bag Inventory is a term coined by the action of a patient bringing his or her medication containers, often in a brown paper bag, to an episode of care whereby the clinician reviews the patient’s medication containers with the patient in an effort to compile an accurate list of the medications the patient is currently taking.

(3) Clinical Encounter. This is an appointment with a provider that may reasonably be expected to involve a patient’s medication regimen.

(4) Health Care Team. Consists of all individuals that are involved in providing health care to the Veteran patient including the providers, nurses, pharmacists, technical and administrative support staff.

(5) Local VA Medications. Local VA medications are medications ordered at the treating VA Facility.

(6) Medication. Any prescription medications, supplies, herbal remedies, vitamins, nutritional supplements, over-the-counter drugs, and any product designated by the Food and Drug Administration (FDA) as a drug.

(7) 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.

(8) Medication Education List. This includes medications from our VA providers, non-VA

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Medical Center Numbered Memorandum 11-1 providers (outside the VA Healthcare System), other VA providers (not Detroit), andnon-prescriptions, vitamins, herbals, & other nutritional supplements.

(9) 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 themedication 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.

(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.

(10) Non-VA Medications. Non-VA medications are non-VA provider prescribed medications filled at non-VA pharmacies, VA provider prescribed medication filled at non-VA pharmacies, herbals, over-the counter-medications, nutraceuticals, and alternative medications.

(11) 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 Veteran patients outside of VA. This includes services reimbursed by Community 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.

4. RESPONSIBILITY

(1) The Chief of Staff is responsible for implementing and maintaining the policy and procedures set forth in this document.

(2) All Clinical Service Chiefs will ensure the medical staff and other providers with prescriptive privileges are educated, trained, aware of, and comply with this policy.

5. PROCEDURES

a. Patient-Centered medication reconciliation must include the following:

(1) The health care team will assist the patient, caregiver, or family member to maintain, updated, 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. As such, the patient’s caregiver or family member should share with the patient’s health care team:

(a) The Veteran patient’s goals of care

(b) Personal medical utilization

(c) Problems which affect medication adherence, such as:

-Allergies and/or ADRs -Difficulties with access to health care -Financial hardship -Recommended medication treatment plan declined or -Other health-system, condition, or therapy-related factors

(d) Non- VA medication and provider information from other VAMC facilities

(e) Any medication and provider information from other VAMC facilities and

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(f) The patient’s health care proxy, if there is one.

(2) The provider will make a good faith effort to obtain medication information from the patient/surrogate and review the medications documented in the electronic medical record (CPRS); including active medications, expired medications, discontinued medications, remote medications and OTC products. There should be a comparison of all outpatient medications with those prescribed on admission. Any discrepancies will be noted and addressed by the provider. If no discrepancies are found it should be noted as none. The veteran’s complete and current medication list with medication name, dose, & frequency, including VA and Non-VA medications is located on the Med tab in CPRS, providing a central location that all services caring for the veteran can access. Also provided on the reports tab, under Health Summary is the Medication Reconciliation Report, which any provider can print and review. Every effort should be made to utilize medication reconciliation templates when performing medication reconciliation.

(3) The health care team will explain the importance of managing medication information to the patient/surrogate during clinical encounters. The patient will be coached and encouraged to take ownership of managing their medication information and emphasizing the importance of maintaining, updating and possessing a current medication list.

(4) Any ADR identified during the medication reconciliation process must be recorded utilizing the ADR report process.

(5) Allergy Assessment – The health care team will obtain information on any known allergy or adverse reaction to food, drugs or other substances and documenting it in the Allergies section under the “Cover Sheet” tab of CPRS.

b. Inpatient Medication Reconciliation:

(1) The provider will interview the patient/caregiver to initiate the medication reconciliation process, comparing the patient’s active outpatient medications, and current inpatient medications. If medications on the patient’s VA outpatient medication list are discontinued during the hospital stay, the provider will note this in the plan of care. Change of medication and/or dose will be explained in the plan of care.

(2) During the patient’s inpatient stay, as medication orders are processed, the pharmacist will assist in checking the current inpatient medications to ensure there are no discrepancies in the active inpatient medication list. If discrepancies are found, the pharmacist will notify the provider for appropriate action.

(3) Inpatient Transfer of Care to a New Setting, Service, Provider, or Level of Care. The receiving provider at the new setting, service, or level of care will initiate the medication reconciliation upon transfer. As medication orders are processed, the pharmacist will assist in checking the current inpatient medications to ensure there are no discrepancies in the active inpatient medication list. If discrepancies are found, the pharmacist will notify the provider for appropriate action.

(4) Inpatient Discharge

(a) The provider will enter the discharge medications for the patient through the outpatient section of the “Orders Tab” of CPRS. Providers will review medications during discharge and include in the discharge note. A reconciled medication list will be generated for the patient from the discharge note.

(b) The designated pharmacist will finish the orders ensuring that discharge orders and active outpatient orders are reconciled. If discrepancies are found, the pharmacist will notify the provider for appropriate action.

(c) Nursing will assist in reviewing that discharge orders and active outpatient orders are reconciled. If discrepancies are found, they will notify the provider for appropriate action. If the patient has new medications or changes in medications, the patient will be counseled, and documented in the progress note.

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c. Outpatient Medication Reconciliation

(1) Primary Care and CBOCs:

(a) Patients will be reminded to bring a current list of all medications or all medication bottles that they are taking to their primary care appointment. A list of VA and non-VA medications is generated prior to each clinic appointment by ward administration for the patient to review.

Nursing staff will assist the patient in reviewing the list of medications as appropriate.

(b) At each primary care visit, the process will include medication reconciliation with a review of the patient’s list against the CPRS medications (active, suspended, expired, discontinued, OTC and non-VA medications) listed in the patient’s record and a review of remote medications (if applicable). Any discrepancies between the patient’s list and CPRS should be resolved with the patient, and the appropriate changes made to CPRS and to the patient’s medication list.

(c) Medication reconciliation will occur any time a medication is ordered, changed or discontinued by the provider. Remote Data Interoperability will generate an order check if an active order exists for the patient at another VA Medical Center.

(d) The updated medication list will be given to the patient/surrogate at the conclusion of the visit.

(e) If the patient is participating in co-practice management of his medical care outside of the VA system, the patient will be encouraged to share the updated(reconciled) medication list with his/her non-VA provider.

(f) If the patient requests to see the pharmacist during normal business hours, the pharmacist will review the medication profile. The pharmacist identifies and clarifies with the ordering provider any medication discrepancies identified. The pharmacist provides the patient with an updated Medication List and documents counseling in the Pharmacy Education/Medication Reconciliation note if changes have been made to the medication list.

(g) Patients are responsible for securing patient sensitive information provided to them.

Patients additionally are responsible for updating and sharing their medication lists with VA providers, as well as, Non-VA providers when changes occur.

(2) Specialty and Special Care Areas

(a) Medications will be reconciled prior to ordering or administration in any area outside of an inpatient setting.

(b) In areas where conscious sedation is administered, medication reconciliation will occur prior to the induction of sedation.

(c) Patients will be reminded to bring a current list of all medications that they are taking to their specialty care appointment. If the patient presents without the list, the clerk will generate a list for the patient to review.

(d) Medical specialists, dental and surgical care providers will reconcile medications within their specialty practice. Providers should use their best clinical judgment when writing or administering medications where a full medication reconciliation process is not performed. (For example, use of contrast media in patients receiving Metformin). Providers should be cognizant of remote order view ability to prevent duplication of medication(s) being provided by another facility.

(e) If medication changes are made, the provider will update the medications in CPRS and on the patient’s medication list. The list will be given to the patient/surrogate at the conclusion of the visit.

(f) If the patient is participating in co-practice management of his/her medical care outside of the VA system, the patient may share the updated (reconciled) medication list with his/her non- VA provider.

(3) Home Based Primary Care (HBPC)

(a) The provider enters any medication changes into CPRS as orders and provides an updated medication list to the patient.

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(b) The HBPC nurse reviews the medication list with the patient on each visit. The nurse asks the patient/caregiver if there have been any changes. If there are changes, the nurse compares what the patient is telling them to the list (where all changes should have been made). If there is disagreement between patient and list, the nurse lets the patient know the last written changes but notes what the patient tells them. The nurse contacts the provider and gets the order reconciled.

(b) The HBPC pharmacist assists in the medication reconciliation by providing recommendations to the HBPC provider/team on medication discrepancies and concerns.

d. Coordination of Care for Non-VA Medication Reconciliation

(1) The patient will be given a Medication Worksheet that contains the most current and up to date medication list at the conclusion of each visit. The provider or nurse will explain the importance of managing medication information to the patient/surrogate. The patient/surrogate will also be encouraged to share the current medication worksheet with their other non-VA providers to increase communication, coordination and continuity of care.

(2) The provider or nurse will make a good faith effort to communicate the patient’s medication information and review the medications documented in the electronic medical record; with other non-VA providers.

e. Monitors Currently there exist several pilot EPRP monitors, at a minimum the EPRP monitors and the IPEC data should be utilized for tracking. Other means of tracking may be utilized at the discretion of the service or QM department.

6. REFERENCES

VHA Directive 2011-12 Medication Reconciliation The Joint Commission on Accreditation of National Healthcare Organizations-National Patient Safety Goals

7. FOLLOW-UP RESPONSIBILITY

The Chief of Staff is responsible for the contents of this Medical Center Numbered Memorandum. Questions may be referred to the Chief of Staff.

8. RESCISSION

Medical Center Numbered Memorandum 11-1 dated April 15, 2013

9. EXPIRATION DATE

May 23, 2023 Pamela Reeves, M.D.

Médical Center Director Distribution: Facility Wide