D23 LOCAL POLICY MEDICATION RECONCILIATION.docx

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

G.V. (SONNY) MONTGOMERY VA MEDICAL CENTER

Medical Center Policy Number: F-11-59 July 27, 2016

MEDICATION RECONCILIATION

I. PURPOSE:

To define the procedures for Veterans receiving treatment by the G.V. (Sonny) Montgomery VA Medical Center for obtaining and maintaining a complete and accurate list of each Veteran’s current medications. Veterans are most at risk during transition in care across patient care settings, services, providers, and levels of care. Reconciliation and communication of a complete and accurate medication list throughout the continuum of care is essential in reducing the risk of transition related drug events. The compilation of the complete list of medications is the responsibility of the clinical staff including physicians, physician’s assistants, nurse practitioners, nurses, pharmacists, and dieticians. Medications include all VA prescribed, non-VA prescribed, over-the counter, herbals, vitamins, nutraceuticals, and respiratory therapy-related drugs such as inhalers that the Veteran takes on a routine basis.

II. POLICY:

A. It is VHA policy that all eligible Veterans cared for within the VA system receive well-coordinated, safe, appropriate and patient-centered medical care at all levels and transitions of the health care continuum as it pertains to the management of patient medication information. Medication reconciliation is an important component in avoiding medication errors and keeping Veterans safe. It is one of The Joint Commission's (TJC) Patient Safety Goals. Medication Reconciliation helps to avoid medication omissions, duplications, dosing errors, or drug interactions.

B. Medication Reconciliation. Medication Reconciliation is a process to ensure maintenance of accurate, safe, effective, and, above all, patient centered medication information by:

1. Obtaining medication information from the Veteran, caregiver, or family members.

2. Comparing the information obtained from the Veteran, caregiver, or family member to the medication 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.

3. Assembling and documenting the medication information in the VA electronic medical record.

4. Communicating with the Veteran, caregiver, or family members regarding updated medication information with provision of education and assessing Veteran/caregiver or family understanding with accommodations for any learning barriers.

5. Communicating relevant medication information to and between the appropriate members of the VA and non-VA health care team.

III. DEFINITIONS:

A. Adverse Drug Event (ADE). An ADE is an injury from the use of a drug. Under this definition, the term ADE includes harm caused by the drug (adverse drug reactions and overdoses) and harm from the use of the drug including dose reductions and discontinuation of drug therapy.

B. Adverse Event and Close Call Reporting. Adverse event and close call reporting is the reporting, review, or analysis of incidents involving Veterans that cause harm or have the potential for causing harm.

C. 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.

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

E. Local VA Medications. Local VA medications are medications ordered at the treating VA facility.

F. Medication Adherence. Medication adherence refers to the extent to which the use of a medication by a Veteran aligns with the stated medication use instructions.

G. Medication Discrepancy. Medication discrepancies are unintentional differences found in the Veteran’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 Veteran or the health care system.

H. 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.

I. 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 Fee-Basis, 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.

J. Patient-focused Local Metrics. Patient-focused local metrics are metrics established at the local level. For example, discrepancy rates, the rates of unintentional differences found in the patients’ medication information when compared to the medication information available on the VA electronic medical record, may be used.

K. Patient Medication Information. Patient medication information is information on all the medications taken by the Veteran, how they are taking it, any problems they may be having and/or have had in the past. This may be obtained by brown bag inventory, verbal history, or patient, caregiver or family member-furnished medication list.

L. Remote VA Medications. Remote VA medications means medications ordered at any other VA facilities (viewed or imported via remote data view).

M. VA Medication Reconciliation External Review Process (EPRP). EPRP is the process for chart review, including the minimum documentation requirements that provide evidence that Medication Reconciliation was performed at this episode of care.

N. VA Medication Reconciliation Performance Monitor. A VA Medication Reconciliation Performance Monitor includes two questions at the post discharge call process: “Did you receive an updated medication list when leaving this VA medical facility?” and “Do you know where to go to ask questions?”

O. VA Providers. VA providers are physicians, medical trainees, advanced practice nurses, physician assistants, and other health care professionals who provide primary care or specialty care within the limitations of their individual VA privileges or scopes of practice.

P. Veterans Receiving Dual Care. Veterans receiving dual care refers to Veterans who receive ongoing health care in both VA and non-VA health care settings.

IV. RESPONSIBILITY:

A. The Medical Center Director is responsible for overall implementation of policy in accordance with VHA Directive and National Patient Safety Goals.

B. The Medical Center Chief of Staff (COS). The Facility COS is responsible for ensuring:

1. VA providers are adequately trained and educated on the Medication Reconciliation process and understand its importance in the scope of quality Veteran care and patient safety.

2. VA providers are knowledgeable about their lead role and responsibilities with respect to Medication Reconciliation.

a. VA providers have been provided sufficient resources for inter-provider, inter-departmental, inter-facility, and inter-system communication which conforms to all relevant VA and VHA privacy policies and Federal law.

C. The Chief of Pharmacy is the designated Facility Medication Reconciliation point of contact (POC) who can receive information and help disseminate new knowledge of Medication Reconciliation transferred from the VISN POC to staff.

D. Each clinical service chief will be responsible for providing a copy of this policy to their staff and ensuring compliance.

E. All providers are responsible for the procedures outlined in this policy to help ensure patient safety is enhanced through the avoidance of medication errors, medication discrepancies and unsafe drug interactions. (Refer to procedures guidelines in next section)

V. PROCEDURES:

A. G.V. Sonny Montgomery providers with prescriptive authority will:

1. Prescribe all medications using the Computerized Patient Record System (CPRS) order entry. Note: New prescriptions that are written using CPRS order entry are automatically integrated into the Veteran’s list of current medications including medications that are being discontinued or changed.

2. Enter medications into CPRS prescribed by non-VA providers and over-the-counter medications (including herbals/vitamins) that the Veteran has chosen to take (using Non-VA Medication tab) even if the JVAMC provider does not endorse their use.

3. Review any medication and provider information from other VAMC facilities (remote data).

4. Document a plan to address medication discrepancies that is commensurate with the severity of the discrepancy and the risk of patient harm. NOTE: Addressing a discrepancy does not always require managing a medication or changing the medication order.

5. Educate Veterans identified as dual care users as per VHA's National Dual Care Policy.

6. Work with Pharmacy to document and report adverse events and close calls as defined by VHA Directive.

7. Educate Veteran, caregiver, or family member to maintain an updated medication list at all times. As such, the Veteran, caregiver or family member should share with the Veteran’s health care team problems which affect compliance with medications including social/financial barriers.

8. Identify health proxy if there is one.

9. Document medication education, counseling and understanding of changes to current medication regimen and or new medication added based on the individual needs of the Veteran, caregiver or family member.

B. ADMISSION (Inpatient/Community Living Center (CLC)/Palliative Care): Providers will document medication reconciliation procedure at the time of admission/hospitalization. Comment by Department of Veterans Affairs: words with too many spaces on this line

1. The G.V. Sonny Montgomery provider (staff physician/resident physician, physician assistant or nurse practitioner as appropriate) responsible for the inpatient care will verify, clarify and reconcile the Veteran’s medication regimen as soon as clinically indicated and documented no later than 24 hours after admission.. The providers will use the CPRS templated admission progress notes (e.g., H&P, interval note, staff admission note) to document the medication reconciliation procedure.

2. The G.V. Sonny Montgomery provider will verify the Veteran’s medication regimen by eliciting from the patient/family/significant other (as appropriate) what medications (including those prescribed by non-VA providers and over-the-counter medications/herbals/vitamins/nutraceuticals/respiratory inhalers) the Veteran is actively taking. This also includes noting any discrepancies from the VA prescription (e.g. stopping a medication due to side effects, not being able to take a medication because it was not refilled, etc.). Comment by Department of Veterans Affairs: complete words on this line

3. Once a good faith effort has been made to obtain what medications the Veteran is actively taking, the G.V. Sonny Montgomery provider will clarify the Veteran’s medication regimen to determine whether the medications should be continued or discontinued based on the patient’s current condition and anticipated treatment. Examples where this might occur would be holding/stopping antihypertensive medications in the face of hypotension, holding/stopping anticoagulants in the face of active bleeding, etc.

C. TRANSFER: G.V. Sonny Montgomery providers will document medication reconciliation at the time of transfer to a different provider, different discipline or different level of care where medications are re-written (such as when a Veteran transfers to/from an ICU setting or transfers from Medicine to Surgery). For all inpatient transfers it is also required that the Veteran’s list of home medications (available in the Medication Reconciliation template completed at the time of admission) be reviewed to determine whether these home medications should be resumed now that the Veteran’s condition has changed. The G.V. Sonny Montgomery provider responsible for accepting the care after the transfer will verify the Veteran’s medication regimen by reviewing the Veteran’s active (current) inpatient, outpatient, and non-VA medication regimen list. The providers will use the CPRS templated CM – TRANSFER PROGRESS NOTE to document the medication reconciliation process.

D. DISCHARGE: Inpatient/CLC/Palliative Care Providers will document medication reconciliation at the time of discharge.

1. The provider will clarify the Veteran’s medication regimen considering the Veteran’s current medical condition and anticipated treatment to determine whether some medications should be discontinued because they would no longer be clinically appropriate at home or whether some medications which were initially held/stopped on admission need to be restarted when the patient goes home. Examples might be an additional medication added for a new symptom near the time of discharge or the restarting of an over-the-counter/herbal/vitamin that the Veteran had not been taking in the hospital, but will restart at home.

2. The provider will reconcile the medication regimen using CPRS (including use of the Non-VA Medication orders as appropriate). The providers will use the CPRS templated CM – FINAL PROGRESS NOTE to document the medication reconciliation process prior to the Veteran leaving the hospital. NOTE: For the CLC, the provider will document medication reconciliation in the FPN and /or Discharge Summary.

3. Following the discharge medication reconciliation process, the Veteran will be given a current list of active medications by the nurse (Shared Templates, Medication folder, Medication List for Patients) and advise Veteran to retain list for future appointments.

E. OUTPATIENT CLINIC: The G.V. Sonny Montgomery provider will verify, clarify and reconcile the Veteran’s medication regimen during the outpatient visit and document the process prior to the Veteran being released from the clinic. The providers will use the Medication Reconciliation template in CPRS to document this process.

1. At the time of check-in to a clinic or for a procedure, the clinic clerk/nurse will print a copy of the Veteran’s current outpatient medication profile, using CPRS.

2. The Veteran will be asked to review the list for accuracy and make note of any medications on the list that are not being taken. He/she will be asked to make note of any non-VA medications (e.g., over the counters, herbals, prescription drugs from other sources, etc.).

3. Nurse/ Provider will review medication sheet with Veteran and advise Veteran to retain list for future appointments.

4. The medication list will be given to the provider. The provider is responsible for reviewing, completing, making new changes as needed and documenting the reconciliation process in CPRS templated notes.

5. Amendments should be handwritten on medication list and documented in CPRS and can be used for additional appointments that day.

NOTE: For follow-up visits to primary care or specialty care clinics, it should be expected that the active medication list will be reviewed, but does not require formal reconciliation unless the Veteran is undergoing an outpatient procedure that requires IV sedation or IV contrast media; new medications are being prescribed; or changes are made to existing prescriptions.

F. EMERGENCY DEPARTMENT ENCOUNTER: Providers will document medication reconciliation in the Emergency Department (ED) if medications are prescribed. The G.V. Sonny Montgomery provider will verify, clarify and reconcile the Veteran’s medication regimen during the ED visit and document the process prior to the Veteran being discharged. The providers will use the Medication Reconciliation template in CPRS to document this process.

1. At the time of check-in to the ED, the MAS clerk will print a copy of the Veteran’s current outpatient medication profile, using CPRS.

2. The Veteran will be asked to review the list for accuracy as appropriate and make note of any medications on the list that are not being taken. He/she will be asked to make note of any non-VA medications (e.g., over the counters, herbals, prescription drugs from other sources, etc.).

3. Amendments can be handwritten by provider on medication list and documented in CPRS.

4. If the Veteran is to be admitted the responsibility for medication reconciliation will be that of the admitting team.

G. A list of the Veterans medications will be communicated to providers outside the VA, provided the patient has completed a “Release of Information.”

1. Veterans who are being cared for by providers outside of the VA should be informed that a list of their current medications are available to be provided to the outside provider.

2. The Veteran must complete a “Release of Information”, specifying the name of the physician to whom the list is to be provided. The Release of Information is forwarded to the Release of Information Department who will complete the process.

H. Mental Health Intensive Case Management (MHICM)

1. The G.V. Sonny Montgomery provider will verify, clarify and reconcile the Veteran’s medication regimen upon admission and during outpatient provider visits. The provider will use the Medication Reconciliation MHICM template in CPRS to document this process.

2. The Veteran will be asked to review the list for accuracy and make note of any medications on the list that are not being taken. He/she will be asked to make note of any non-VA medications (e.g., over the counters, herbals, prescription drugs from other sources, etc.).

3. Provider will review medication sheet with Veteran. Provider will advise Veteran to retain list for future appointments and document changes in CPRS and on list provided to Veteran.

4. The medication list will be obtained by the provider. The provider is responsible for reviewing, completing, making new changes as needed and documenting the reconciliation process in CPRS templated notes.

5. Amendments should be handwritten on medication list and documented in CPRS.

I. Home Base Primary Care (HBPC):

1. The G.V. Sonny Montgomery provider will verify, clarify and reconcile the Veteran’s medication regimen upon admission and during outpatient visits. The providers will use the Medication Reconciliation template in CPRS to document this process.

2. The Veteran/caregiver will be asked to review the list for accuracy and make note of any medications on the list that are not being taken. He/she will be asked to make note of any non-VA medications (e.g., over the counters, herbals, prescription drugs from other sources, etc.).

3. Provider will review medication sheet with Veteran/caregiver and advise Veteran/caregiver to retain list for future appointments.

J. Reporting Requirements: Aggregate results will be reported to Patient Safety to be included (summary review) in the QSV and CEB minutes quarterly.

VI. REFERENCE:

1. VHA Directive 2011-012, Medication Reconciliation, March 9, 2011;

2. Joint Commission National Patient Safe Goals, CAMH Update 1, March 2011

3. VHA DIRECTIVE 2009-038, VHA National Dual Care Policy

VII. RESCISSION:

/s/ David M. Walker, MD, MBA, DFAPA Medical Center Director

Attachments: None

EXPIRATION DATE: July 27, 2019

RESPONSIBLE OFFICE: Chief Of Staff (11)