D.8 MCM 658-11-75 Med Recon (2019).pdf

Department of Veterans Affairs VAMC MEMORANDUM 658-11-75 VA Medical Center September 22, 2016 Salem, VA 24153

MEDICATION RECONCILIATION

1. PURPOSE: To establish a consistent process for accurately and completely reconciling patient medications across the continuum of care at the Salem VA Medical Center (VAMC).

2. POLICY: Medication reconciliation is the process of ensuring the maintenance of accurate, safe, and appropriate medication information. It is the policy of the Salem VAMC to ensure our Veterans receive well-coordinated, safe, appropriate, and patient-centered medical care at all levels and transitions within the health care continuum as it pertains to the management of patient medication information.

3. DEFINITIONS:

a. Medication Reconciliation. Medication Reconciliation is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions and interactions and the need to continue current medications. Through medication reconciliation, maintenance of accurate, safe, effective and patient centered medication information is ensured.

b. Medications. Medications include those prescribed by the organization, by other health care providers, and agents purchased over-the-counter (OTC) such as OTC drugs, herbals, vitamins, etc., by the patients.

4. RESPONSIBILITES:

a. The Chief of Staff is responsible for ensuring medication reconciliation processes are standardized, established, and maintained throughout the medical center and affiliated sites of care.

b. The Pharmacy and Therapeutic Committee will assist the Chief of Staff in monitoring the performance of medication reconciliation.

c. The reconciliation process is a shared responsibility between providers, pharmacists, and nurses. This process also includes responsibility for documenting and reporting adverse medication events and close calls into CPRS and the electronic patient incident reporting system as defined by VHA policy regarding Adverse Drug Event Reporting and Monitoring (VHA Directive 2008-59) and Patient Safety Improvement (VHA Handbook 1050.01).

d. The patient is responsible for:

(1) Being an active and responsible partner in his/her health care.

D.8 MCM 658-11-75 Med Recon (2019) 36C24621R0068

VAMC MEMORANDUM 658-11-75

(2) Informing providers of any changes in their medication regimen.

5. ACTION:

a. Outpatient encounter:

(1) New patients will be educated during patient intake process:

(a) To be a responsible partner in his/her health care.

(b) To bring a list of their current medications, including OTC medications and supplements, to their appointment for review with their new provider.

(c) At every encounter, they will be expected to inform their provider of any changes that have been made to their medical regimen (including medications they are not taking, dosages, frequency, and routes).

(2) Provider will document reconciliation of medications on the initial intake (typically this is in Primary Care or Mental Health Clinics) using the Medication Reconciliation template.

(3) Returning/Current patients will:

(a) Bring a list of their current medications, including herbals, OTC medications, nutraceuticals, and alternative medications to their appointment for review with their provider.

(4) Providers will:

(a) Obtain medication information, including herbals, OTC medications, nutraceuticals, and alternative medications, from the patient, caregiver, or family member. Review and compare medication information from all available sources, including active medications, recently expired medications, the Outpatient Medication Profile, previous inpatient medication regimen, outside medical records, remote data in CPRS, and any medication bottles brought by the patient.

(b) Verify the medication regimen the patient is following.

(c) Resolve any identified discrepancies between what the patient is taking and what has been prescribed. Highlight the discrepancies identified and addressed. If unable to resolve a discrepancy, contact the prescribing provider.

(d) Communicate changes/new medications to the patient and provide education to the patient, caregiver, or family member. Document changes in the medical record and provide the patient with a written copy of the accurate medication list.

(e) Communicate relevant medication information to and between the appropriate members of the health care team.

(f) Instruct the patient to properly dispose of medications he/she is no longer taking.

(g) Reconcile the Outpatient Medication Profile in CPRS by:

1. Discontinuing medications;

2. Ordering new medications and any dosing or schedule changes;

3. Updating non-VA medication list in CPRS; and

4. Documenting treatment plan in a progress note.

5. Ensuring medication orders are written in a timely manner.

(h) Document medication reconciliation in the clinic (this includes specialty clinics) progress note using the medication reconciliation template only when new chronic medications are being prescribed.

(5) Pharmacists will:

(a) Review medication orders, compare medication profiles, and verify medications.

(b) Notify provider of any discrepancies, provide recommendations for resolution, and request the provider to correct the discrepancy in a new medication order.

(c) Fill prescriptions.

(d) Offer verbal patient education for all new prescriptions which are picked up at the pharmacy. Written education is provided with all prescriptions received through the mail or at the pick-up window.

(f) Document and report adverse events and close calls into CPRS and ADERS as defined by VHA policy regarding Adverse Drug Event Reporting and Monitoring.

b. Inpatient Procedures:

(1) On admission, the provider will:

(a) Review existing medication information, including herbals, OTC medications, nutraceuticals, and alternative medications, from all available sources, including the Outpatient Medication Profile, previous inpatient medication regimen, outside medical records, and remote data in CPRS.

(b) Interview patient (and/or caregiver/family member) and confirm medication regimen the patient is following.

(c) Order inpatient medications.

(d) Make changes to the medication profile for the discrepancies identified.

(e) Educate house staff on the correct medication reconciliation process as outlined in this MCM.

(f) Ensure that house staff is reconciling medications across the continuum of care.

(g) Complete the medication reconciliation template in CPRS.

(2) On admission, the Clinical Pharmacy Specialist will:

(a) Compare admission orders against the Outpatient Medication Profile.

(b) If discrepancies are found between inpatient orders and outpatient profile, the

Clinical Pharmacy Specialist will correct discrepancies and notify provider of change(s).

(c) Screen and verify the medication orders.

(3) On admission, the registered nurse will:

(a) Review the medication list, which is generated automatically in the nursing database, and review it with the patient.

(b) The nurse will notify the provider of any identified discrepancies (i.e., medications taken as outpatient but not on the list, dose discrepancies, and OTC medications).

(4) At the time of discharge, the provider will:

(a) Review inpatient medications to determine the patient’s discharge regimen.

(b) Discontinue obsolete medications from the Outpatient Medication Profile.

(c) Order discharge medications.

(d) Order a sufficient quantity of medication to last until the patient’s next outpatient visit.

(e) Update the non-VA medication list.

(f) Communicate the medication regimen to the patient, caregiver and/or family member, with emphasis on any changes/new medications prescribed at discharge.

Written discharge instructions will be provided and patients will also be referred to the final written medication list (Outpatient Medication Profile) provided by Pharmacy.

(g) Document in the discharge progress note and discharge summary the entire medication regimen the patient will be following upon discharge.

(h) Complete the medication reconciliation template in CPRS.

(5) At the time of discharge, the registered nurse will:

(a) Instruct/remind the patient of his/her responsibility to wait for discharge medications, pharmacy counseling, and discharge instructions prior to leaving the facility.

(b) Provide patient education and review medication list with patient upon discharge when pharmacist is unavailable.

(6) At the time of discharge, the pharmacist will:

(a) Compare discharge orders with the previous inpatient regimen and active outpatient profile.

(b) Communicate any discrepancies to the provider. If discrepancies are found, the pharmacist will request that the provider make any necessary change(s).

(c) For all discharge medications the patient was taking as an outpatient, the pharmacist will determine if their supply at home is sufficient or if a new order is needed.

(d) Screen and verify the discharge medication orders.

(e) For patients that present to the pharmacy, the patient will be offered education/counseling.

c. Transfer Procedures (to another setting, service or provider):

(1) On transfer, the sending provider will:

(a) Write medications for transfer based on the regimen the patient is receiving at his/her current inpatient location.

(b) If delayed transfer orders have been written, the sending provider will review the orders to ensure that any medication changes made between the time the delay orders were written and the transfer occurred are included in the transfer orders.

(2) On transfer, the receiving provider will:

(a) Review inpatient and transfer medications to determine current regimen.

(b) Document medication reconciliation.

(3) On transfer, the Clinical Pharmacy Specialist will:

(a) Compare transfer orders against the previous inpatient medication regimen.

(b) If discrepancies are found between inpatient orders and transfer orders, the

Clinical Pharmacy Specialist will correct discrepancies and notify provider of change(s)).

d. Pre-operative/Pre-procedure Medication Reconciliation:

(1) To reduce potential medication-related risk for patients having surgery or other procedures involving anesthesia or sedation (moderate/deep), the provider and/or Pre- Admission Clinic will:

(a) Review existing medication information, including herbals, OTC medications, nutraceuticals, and alternative medications, from all available sources, including the Outpatient Medication Profile, previous inpatient medication regimen, outside medical records, and remote data in CPRS.

(b) Interview patient (and/or caregiver/family member) and confirm medication regimen the patient is following.

(c) Order (or discontinue) medications, if needed/indicated, for the pre-operative/pre-procedure preparation process.

(d) Make changes to the medication profile for the discrepancies identified.

Communicate changes/new medications to the patient and provide education to the patient, caregiver and/or family member.

(e) Document the changes and the medication reconciliation process in the Pre-

Admission Clinic notes, to include the Medication Reconciliation template.

(f) At the end of the Pre-Admission Clinic encounter, the patient will be provided medication information regarding any short-term medication(s) prescribed for pre-op/pre-procedure care during that encounter. A complete list of the patient’s on-going medications is not required.

(g) When procedures with moderate sedation are planned without Pre- admission

Clinic encounter, the provider will review existing medication information before the procedure including herbals, OTC medications, nutraceuticals, and alternative medications, from all available sources, including the Outpatient Medication Profile, previous inpatient medication regimen, outside medical records, and remote data in CPRS. This medication review will be reflected in the Pre-Sedation note in CPRS. The patient will be provided medication information containing any short-term medication(s) or changes prescribed for post procedure care during that encounter. A complete list of the patient’s on-going medications is not required.

(h) When imaging studies utilizing intravascular contrast or local anesthesia are performed, the provider or the radiologist reviews the current list of medications to assure no contraindications to treatment exist. In the event a patient is currently taking a drug containing Metformin, the patient will be instructed and given a written form to discontinue the drug for 48 hours (as documented in Radiology policy # 50). If there are no medication changes following the imaging study, the patient is not required to receive a new medication list.

(i) Patients requiring anti-coagulation bridging therapy in preparation for surgery or procedures will be referred to the Anti-Coagulation Clinic using the Anticoagulation Management consultation in CPRS for appropriate management.

(2) Anticoagulation Clinic Pharmacists will:

(a) Review medication profiles, order and/or revise anticoagulation medications as needed/indicated for the pre-operative/procedure preparation process.

(b) Communicate changes/new medications to the patient and provide education to the patient, caregiver and/or family member.

(c) Provide written instruction to the patient, caregiver or family member for the anti-coagulation bridging. A complete list of the patient’s on-going medications is not required.

e. Limited Medication Reconciliation in Specific Settings:

(1) In outpatient settings where medications are used minimally or prescribed for short duration only (with no changes to continuous or long-term medications), a modified medication reconciliation process will be performed by the provider.

(2) Examples of such setting include (but are not limited to): Dental Clinic, Emergency Department, Specialty Care Clinics, Surgery Clinics, Day Unit, Ophthalmology/Optometry and Diagnostic Imaging.

(3) A list of the patient’s current medications and allergies is obtained. The information collected may be limited to the name of the medication and if it is taken regularly or episodically (e.g., PRN).

(4) At the end of the encounter, the patient will be provided medication information containing the short-term medication(s) prescribed during that encounter. Communicate the short-term changes/new medications to the patient and provide education to the patient, caregiver and/or family member. It is not necessary to give the patient a complete reconciled medication list.

6. RESPONSIBILITY: Chief, Pharmacy Service.

7. ETHICAL DOMAIN:

a. Shared Decision Making with Patients.

b. Patient Privacy and Confidentiality.

c. Professionalism in Patient Care.

8. REFERENCES:

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

b. The Joint Commission Comprehensive Accreditation Manuals for: Hospital, Nursing Care Centers, and Home Care; current editions.

9. RESCISSION: Medical Center Memorandum 658-11-75, Medication Reconciliation dated February 10, 2014.

10. EXPIRATION: September 22, 2019.

Rebecca J. Stackhouse, CTRS, FACHE Medical Center Director