D.4 Medication Reconciliation, HPM 589A4-370 VAMC, 36C25522R0052.pdf

Department of Veterans Affairs Harry S. Truman Memorial Veterans' Hospital

800 Hospital Drive Columbia, MO 65201

HPM 589A4-370

September 27, 2017

Issued by: COS/Pharm

MEDICATION RECONCILIATION

1. PURPOSE: To delineate the procedure for medication reconciliation at this facility.

2. POLICY: Medication reconciliation is defined as "The process of comparing a patient's medication orders to all of the medications that the patient has been taking, with the involvement of the patient." It is required by The Joint Commission (TJC). This process is required to avoid medication errors including omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medication will be prescribed, administered, modified, or may influence the care given and will be done across the continuum of care applying to all care settings including ambulatory, emergency and urgent care, long term care, and home care as well as inpatient services. Medication errors related to medication reconciliation typically occur when a patient is admitted to, transferred within, or discharged from a health care facility. The medication reconciliation process comprises five steps:

a. Develop a list of current VA, non-VA, over-the-counter, and homeopathic medications.

b. Develop a list of medications to be prescribed.

c. Compare the medications on the two lists.

d. Make clinical decisions based on the comparison.

e. Communicate the new list to the appropriate caregiver and/or patient, and provide a copy of the new list to the caregiver and/or patient.

3. PROCEDURE:

a. The "list" of current medications at this facility is synonymous with the list of Inpatient, Outpatient, and non-VA medications as documented on the patient's Computerized Patient Record System (CPRS) "Meds" tab. This list is automatically updated when medication orders and non-VA medications are entered into the CPRS computer system.

b. Physicians, Pharmacists, Nurses, Veterans, and patient family members/caregivers are responsible for the reconciliation process. The respective responsibilities are delineated as follows:

(1) For Inpatients:

(a) During admission, the physician(s) will compare each inpatient medication order with the outpatient medication profile, including VA and non-VA medications, to ensure that only appropriate active medications are ordered and the dosages are consistent with what the patient was taking in the outpatient setting. If discrepancies are found, the admitting provider will contact the original prescriber for clarification. Whenever a provider enters new medication orders or renews medication orders, medications being ordered/renewed are compared to the list of current active medication orders. Comparison is performed to identify

D.4 Medication Reconciliation, HPM 589A4-370 VAMC, 36C25522R0052

HPM 589A4-370

September 27, 2017 any omissions, duplications, dosing errors, or drug interactions. To facilitate this process, the active medication list may be pulled into templated notes when indicated. Physicians will involve the patient and/or caregiver in this process by discussing the medications they are currently taking with them. The physician will ask the patient/caregiver about any non-VA medications that the patient is taking, and will enter these medications into CPRS. If necessary, the pharmacist is available to assist the physician with non-VA medications by working with VISN-15 personnel to get new file entries created. The pharmacist may be reached at extension 5-3538 24 hours/day.

(b) Nurses will ensure that, when completing the Nursing Admission Assessment, the active VA and non-VA medication list is reviewed with the patient/caregiver.

(c) During the discharge process, or upon notification that transfer to another care facility is planned, a pharmacist will compare each new medication order received with the active VA and non-VA medication list, and the pharmacist will reconcile the discharge or transfer medications ordered with the inpatient medication orders. All discrepancies will be brought to the attention of the prescriber for clarification or correction.

During the discharge process, the pharmacist will provide the patient/caregiver with a reconciled list of active medications. The delivery of this list will be documented as part of the discharge or transfer medication reconciliation process.

(2) For Outpatients:

(a) Clinical support staff will print a copy of all currently active medications prior to patient’s appointment. During the appointment, the provider will review all VA and non-VA medications to verify accuracy. The provider will update the printed medication list, review with patient and/or caregiver, and provide an updated copy to the patient and/or caregiver. The provider will renew all necessary medications with sufficient refills to provide uninterrupted care until the next anticipated appointment. For chronically administered medications, a full 12 months of refills should be provided.

(b) If a new medication is added to the patient’s medication profile, the patient should be taken to meet with a pharmacist for a medication review and verification before leaving the primary care area. The pharmacist will review all medication changes with the patient, verify all new medication orders, clarify any discrepancies or questions with the provider, and provide a reconciled medication list to the patient and/or caregiver. This action must be documented in the medical record.

4. REFERENCES: The Joint Commission; VHA Directive 2011-012, Medication Reconciliation, March 9, 2011; VHA Directive 1164, Essential Medication Information Standards, June 26, 2015; VHA Directive 2009-038, VHA National Dual Care Policy, August 25, 2009.

5. RECISSION: Hospital Policy Memorandum 589A4-370, dated April 10, 2013.

APPROVED:

DAVID ISAACKS, FACHE DATE: September 27, 2107 Director

Keywords: Medication, Admission, Pharmacy Orders, Nurse, Discharge, Transfer