D9 - Attachment - Medication Reconciliation.pdf

MEDICATION RECONCILIATION

MCP F-11-59

G.V. (Sonny) Montgomery VAMC Center Jackson, Mississippi 39216

Signatory Authority:

G.V. (Sonny) Montgomery VAMC Center Director

Responsible Owner:

GVSMVAMC Chief of Staff

Rescinded Document:

F-11-59, Medication Reconciliation, dated July 27, 2016

Effective Date:

January 27, 2021

Recertification Date:

January 27, 2026

1. POLICY

This medical center policy (MCP) establishes policy on the distribution, management, and communication of the G.V. (Sonny) Montgomery VA Medical Center (GVSMVAMC) Medication Reconciliation.

A. It is the Medical Center 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 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

Month Day, Year MCP F-11-59 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.

2. JUSTIFICATION

To define the procedures for Veterans receiving treatment by the GVSMVAMC 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.

Medication reconciliation consists of:

1. Verifying the medication history as to which medications the patient is taking, which medications have been discontinued (by a provider or by the Veteran) and which medications have been added;

2. Clarifying that the medications and doses are appropriate for the Veteran’s current condition and anticipated treatment; and

3. Reconciling the medication regimen by documenting the changes using the Computerized Patient Record System (CPRS) medication order entry function so the medication profile (list) will be accurate for future providers

3. RESPONSIBILITIES

A. G.V. (Sonny) Montgomery VA Medical Center, Medical Center Director (MCD). The Medical Center Director is responsible for overall implementation of policy in accordance with VHA Directive and National Patient Safety Goals.

B. G.V. (Sonny) Montgomery VA Medical Center, Chief of Staff (COS). The

Facility Chief of Staff 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. G.V. (Sonny) Montgomery VA, Pharmacy Service. 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)

4. OTHER PARAGRAPHS

A. GVSMVAMC 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.

1. The GVSMVAMC 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 GVSMVAMC 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.).

3. Once a good faith effort has been made to obtain what medications the Veteran is actively taking, the GVSMVAMC 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: GVSMVAMC 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 GVSMVAMC 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 GVSMVAMC 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. Outpatient Clinic Face-to-Face Visits:

a. 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.

b. 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.).

c. Nurse/ Provider will review medication sheet with Veteran and advise

Veteran to retain list for future appointments.

d. 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.

e. 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.

2. Outpatient Clinic Telephone/Virtual Visits:

a. The 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 compared with those listed in CPRS. 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.).

b. Amendments to the Veteran’s medication list will be documented in CPRS and the corrected list of active medications will be mailed to the Veteran.

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. The ED Provider will review the medications listed in CPRS with the Veteran for accuracy and make note of any medications on the list that are not being taken. The Veteran will also be asked about any non-VA medications (e.g., over the counters, herbals, prescription drugs from other sources, etc.).

2. Amendments to the Veteran’s medication list will be documented in CPRS and the corrected list of medications will be provided to the Veteran upon discharge from the ED. The Provider will advise the Veteran to retain the medication list for future episodes of care.

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

G. CARE IN THE COMMUNITY: 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 GVSMVAMC 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

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 GVSMVAMC 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

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.

5. DEFINITIONS

A. Adverse Drug Event (ADE). An ADE is an injury from the use of a drug.

This definition includes any harm caused by the drug as a result of adverse drug reactions, drug-drug interactions, product quality problems, or drug overdoses (whether accidental or intentional).

1. Mild ADE. A mild ADE is an event that requires no intervention or minima therapeutic intervention, such as discontinuation of the drug(s).

2. Moderate ADE. A moderate ADE is an event that requires active treatment of an adverse reaction, further testing, or an evaluation to assess the extent of a non-serious outcome.

3. Serious ADE. A serious ADE occurs when a patient’s condition has one or more of the following outcomes (or requires medical intervention to prevent one of these outcomes): death, a life-threatening experience, inpatient hospitalization (or a prolonged hospitalization), a persistent or significant disability, a congenital anomaly, or birth defect.

B. Adverse Event. Adverse events are unpleasant incidents, diagnostic misadventures, therapeutic misadventures, iatrogenic injuries, or other occurrences of harm or potential harm directly associated with care or services provided within the jurisdiction of the Veterans Health Care System.

C. Adverse Event and Close Call Reporting. Adverse event and close call reporting is the reporting of incidents involving patients that cause harm or have the potential for causing harm. Adverse and close call events involving patients should be entered into the Joint Patient Safety Reporting (JPSR) system.

D. Adverse Drug Reaction (ADR). ADR is a response to a drug which is noxious and unintended, and which occurs at doses normally used in individuals for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function.

1. Historical ADR. A historical ADR is a past event or an event that reportedly occurred in the past at another health care setting. A historical ADR is defined in the Computerized Patient Record System (CPRS) as reported by the patient as occurring in the past and no longer requires intervention.

2. Observed ADR. An observed ADR is defined in CPRS as a reaction that is directly observed or occurring while the patient was on the suspected causative agent. NOTE: “Observed” refers to a newly noted adverse outcome. Although the term implies that the provider of record made the diagnosis, the fact that a provider may not have visually “observed” an ADR does not preclude reporting as “observed.”

3. Allergy. An allergy is an ADR mediated by an immune response

(e.g., rash, hives).

E. Brown Bag Inventory. A brown bag Inventory is a health care team’s review or inventory of the medication in their containers. Brown Bag/medication inventories are completed in an effort to compile an accurate list of the patient's current medication use ideally before an encounter, as needed, and from home so the patient does not have to transport all of their medications to an encounter in a VA medical facility.

F. Close Call. A close call is an event or situation that could have resulted in an adverse event, but it did not either by chance or through timely intervention.

These events have also been referred to as “near miss” events.

G. Joint Patient Safety Reporting System. Joint Patient Safety Reporting

System (JPSR) is the national patient safety event reporting software that is used jointly by the Department of Defense and VA. While all safety events can be reported in JPSR, the medication event reports in JPSR tend to be medication errors, close calls or unsafe conditions rather than adverse drug reactions because most drug reactions are reported through a CPRS entry which automatically feed into the VA - Adverse Drug Event Reporting System.

However, ADEs that will be analyzed by RCA will need a JPSR entry in order to link it to the RCA document.

H. Local VA Medications. Local VA medications are medications dispensed by the treating VA facility.

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

J. Medication Discrepancy. Medication discrepancies are 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.

K. Medication History. Medication history is obtained by reviewing with patients and caregivers what medications they are taking/using, how they are experiencing them (efficacy, problems taking, adverse reactions), and if they are having any trouble managing their medications at home. Important:

Medication use is the only component of medication history required in medication reconciliation.

L. Medication Information Management. Medication information management is all the information and related processes patients, caregivers, and their health care teams require for successful, safe, high quality, and patient driven medication care. This includes patient medication information, effective medication review/history, shared and clinical decision making, treatment plan, transitions in care, and hand off. Determining medication use and using that data to inform an updated medication treatment plan is the cornerstone of medication reconciliation which is in turn part of larger medication information management process.

M. Medication Reconciliation. Medication reconciliation is a process of ensuring the maintenance of accurate, timely, and complete medication information by:

1. Obtaining medication use information from the patient, patient’s caregiver(s), or patient’s family member(s) for review.

2. Comparing the information obtained from the patient, patient’s caregiver(s), or patient’s family member(s) to the medication information available in the VA electronic medical record as defined by VHA Directive 1164, Essential Medication Information Standards, dated June 26, 2015, to identify and address discrepancies.

3. Assembling and documenting the medication information in the VA electronic medical record. Communicating with and providing education to the patient, patient’s caregiver(s), or patient’s family member(s) regarding updated medication information as defined by VHA Directive 1164.

4. Communicating relevant medication information to and between the appropriate members of VA and non-VA health care team as defined by VHA Directive 1164.

5. Providing the patient or family member with written information on the medications the patient should be taking when discharged from the hospital or at the end of the outpatient encounter

N. Medication Treatment Plan. Medication treatment plan is a list of all the medications the patient is meant to take, and any information associated with those medications necessary for successful medication care. This includes follow up, diagnostics, and anticipatory guidance.

O. 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. Non-VA medications are comprised of the following elements and are documented in CPRS by the health care team (i.e., providers, pharmacists, nurses and specially trained technicians):

1. Community provider-prescribed medications filled at non-VA pharmacies.

2. VA provider-prescribed medications filled at non-VA pharmacies.

3. Other: Veteran-obtained medication such as herbals, over-the-counter-medications, nutraceuticals, samples, and alternative medications.

NOTE: For additional information see VHA Directive 2009-038, VHA National Dual Care Policy, dated August 25, 2009.

P. 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 health care services not provided by VA and reimbursed by VA via contract or provided through the Department of Defense, TRICARE, Medicare, private pay, or other health insurance.

Q. 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.

R. Patient Medication Information. Patient medication information is information on all the medications taken by the Veteran

1. Patient Medication Information includes:

a. All medications the patient is taking, has added, stopped taking, or takes differently than prescribed.

b. Problems with the medication.

c. If the medication is working or not.

2. Self-management information and tools patient requires for successful medication care at home and for sharing with caregivers and health care teams including how to track medications, journal, report problems, participate in shared decision making, request refills, renewals, and consultation, and medication education.

3. Patient medication information is obtained from the Brown Bag Inventory, a verbal history, the patient, the patient’s caregiver, or the patient’s family members. It can be obtained from electronic tools, like a mobile application or via secure messaging. This information is augmented by inquiries to pharmacies, and health care teams.

S. Prescribing Providers. Providers include physicians, clinical pharmacist/specialists (scope of practice), advanced practice registered nurses, physician assistants, and other health care professionals who provide health care to patients, and for the purpose of medication information management, have the ability to write prescriptions.

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

U. VA Medication Reconciliation Evaluation. VA Medication Reconciliation Evaluation will be performed and reported locally including national peer review quality indicators and are aligned with external and internal mandates.

V. 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.

W. Veterans Receiving Community Care. For purposes of this directive, Veterans receiving community care, refers to Veterans who receive ongoing health care in both VA and in the community health care settings (both paid for by the VA as well as paid for by the Veteran)

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.

3. 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)

6. REFERENCES

A. VHA Directive 2011-012, Medication Reconciliation, March 9, 2011 B. Joint Commission National Patient Safe Goals, CAMHU Update 1, March 2011 C. VHA Directive 2009-038, VHA National Dual Care Policy

Note: This is an internal VA Website that is not available to the public

7. RESCISSION

MCP F-11-59, Medication Reconciliation, dated July 27, 2016, is rescinded

8. REVIEW

This MCP must be reviewed at minimum at recertification. This review is documented on the GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of

January 27, 2026. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

/s/ David M. Walker, MD, MBA, DFAPA G.V. (Sonny) Montgomery VA Medical Center Director

Date Approved: January 27, 2021

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Emailed to the All Employee G.V. (Sonny) Medical Center Email Distribution List on ( ). MCPs are available at: GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?vie wpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx