S02 - Attachment 5 - Number Memorandum 11-91-17 Medication Reconciliation.docx

Attachment 5 Attachment 5

MEDICATION RECONCILIATION

1. PURPOSE: To establish a system-wide approach to managing patient medication information by reconciling medications across the continuum of care.

2. POLICY: This policy defines how the Mann-Grandstaff Veterans Affairs Medical Center (MGVAMC) outpatient and inpatient patient care areas will perform medication list review and reconciliation of the patient medication list.

a. Each inpatient and outpatient patient care area where medications are prescribed or clinical decisions are made, which impact medication use, will have a Standard Operating Procedure (SOP) that outlines how medication review and reconciliation is performed in their area.

(1) SOPs are brief and clearly written publications that provide guidance for use within a service and are considered permanent in nature. These procedures and policies are to be reviewed every three years. SOP updates are initiated at the discretion of the Service Chief. SOPs will also be provided to Quality, Service, and Value (QSV) on an annual basis for review.

(2) The SOPs will follow the outline of medication review and reconciliation in this numbered memorandum.

b. Medication changes shall not be implemented through secure email messaging as this method cannot ensure timely communication with the patient. Secure email messaging may be utilized to reinforce prior verbal or face-to-face communication regarding medication changes, to provide an undated medication list to the patient, or to provide educational material describing the importance of managing medication information and the patient’s personal responsibilities for medication safety.

3. DEFINITIONS:

a. Medications: Pharmacologic substances taken by or administered to the patient for the prevention or treatment of disease. Medications include prescribed and over-the-counter pharmacologic preparations, vitamins, dietary supplements, herbal products, and all other pharmacologic substances utilized for the purpose of perceived health benefits (such as medical marijuana).

b. Medication Discrepancy: A disagreement between a patient’s stated list of active medications and the patient’s Department of Veterans Affairs (VA) medication list, including deletions, additions, or changes in medication dosage, dosing schedule or route of administration.

c. Medication Reconciliation: A process that encompasses the following steps:

(1) Collect accurate, current patient medication information.

(2) Compose the corresponding electronic medical record (EMR) information.

(3) Correct the VA medication list to reflect the medications the patient is advised to take upon conclusion of the clinical encounter or, when unable to do so, provide a mechanism to resolve the remaining medication discrepancies.

(4) Communicate medication changes and provide medication counseling to the patient (and/or the patient’s proxy) prior to conclusion of the clinical encounter. This must include education regarding the importance of managing medication information and the patient’s personal responsibilities in promoting medication safety.

d. Medication Review: The process of reviewing the patient’s active, recently expired, remote, and non-VA medications.

e. Non-VA Medication: Medication, whether prescribed or available without a prescription, dispensed by or obtained from a source other than a VA pharmacy.

f. VA Medication: Medication prescribed by a VA-provider and dispensed by a VA pharmacy.

g. VA Medication List: The list of all local VA, non-VA, and remote VA medications.

h. Procedural Medications: Intravenous contrast, vaccines, pre-procedure anesthetic agents (local, topical, or endotracheal), ocular anesthetic agents, stains and mydriatic agents administered for the purpose of facilitating the ophthalmological examination, and otic lavages are not medication as defined by this facility.

i. Remote Medications: Medications provided by a VA Medical Center outside the MGVAMC.

4. PROCEDURES:

a. Collect accurate, current patient medication information. A comprehensive medication review must be performed in every clinical setting where medications are administered, prescribed, modified, or where clinical decisions are made, including telephone encounters and at every transition of level of care.

(1) The medication list used to review the medications with patient/caregiver/family will include:

(a) Local Active VA Prescriptions.

(b) Remote Active VA Prescriptions.

(c) Non-VA Medications.

(d) Recently Expired VA Prescriptions (90-180 days).

(e) Recently Discontinued VA Prescriptions (90-180 days).

(f) Pending Mediation Orders, where relevant - must have category (may be blank).

(2) The initial review may be performed by licensed nursing staff.

b. Compose the corresponding EMR document.

(1) After reviewing the medication list with the patient/caregiver/family, nursing staff who completed the review will document in the EMR. Documentation must include embedded medication list reviewed, if there were no discrepancies identified, or all medication discrepancies that were identified. Nursing staff completing the medication list review will communicate the medication list discrepancies to the provider caring for the patient.

(2) If the initial comprehensive medication review cannot be completed, there shall be clear documentation in the EMR as to the specific circumstances involved and any additional attempts to obtain the information from an alternate source, such as a family member or caregiver, if available.

(3) The nursing staff member who performs the initial comprehensive medication review shall update the non-VA medication list to reflect the patient’s current list of non-VA medications. Note: Updating the non-VA medication list is a documentation function, not a prescribing function and may be performed by non-provider staff.

c. Correct the VA medication list to reflect the medications that the patient is advised to take upon conclusion of the clinical encounter or hospital discharge, when unable to do so, provide a mechanism to resolve the remaining medication discrepancies.

(1) Revision of a prescribed medication is a prescribing function and must be authorized by a provider. Medication orders will be revised to reflect the patient’s current medication regimen, with communication to secondary providers as appropriate.

(2) Prior to conclusion of the clinical encounter or inpatient discharge, the provider shall address all remaining medication discrepancies in a manner commensurate with the severity of the discrepancy and the risk of patient harm and shall document the specific resolution in the EMR. Medication discrepancies may be resolved by:

(a) Appropriately revising discrepant medication prescriptions that fall within the VA provider’s clinical expertise through training and/or clinical experience.

(b) Directly contacting the prescribing provider (or the provider’s proxy) in situations where the risk of patient harm warrants immediate resolution and the prescription falls outside the VA provider’s clinical expertise through training and/or clinical experience and documenting this in the EMR.

(c) Add ordering provider as a co-signer of the note to address all non-emergent medication discrepancies.

(3) Inpatient discharge medication lists:

(a) The discharging provider will document the intended discharge medication list (including VA, non-VA, and remote medications). If changes are made after the discharge note is signed, an addendum must be added and appropriate staff notified of changes.

(b) If the discharging provider is notified by support staff of unaddressed medication discrepancies, the discharging provider is required to address the discrepancies in a timely manner in order to prevent or minimize the delay in patient discharge. The patient may not be discharged until the medication discrepancies are addressed.

(c) The medications on the provider medication note/summary are to match the medication in the pharmacy/nursing discharge note and should include all active VA, non-VA, and remote VA medications.

d. Communicate medication changes and provide medication counseling to the patient (and/or the patient’s proxy) prior to conclusion of the clinical encounter or inpatient discharge. This must include education regarding the importance of managing medication information and the patient’s personal responsibilities in promoting medication safety.

(1) Medication list will be provided to the patient/family/caregiver at conclusion of the clinical encounter or inpatient discharge. The medication list will include active, non-VA, remote medications, and newly prescribed medications. The discharge medication list is updated including all changes made during the encounter with the patient and has the following essential medical information: name of the drug, instructions/directions for use, patient identification, prescriber, local pharmacy information, and facility contact information.

(2) Documentation in the EMR at the conclusion of the clinical visit or inpatient discharge must include: patient/family/caregiver education, verbalization of understanding of the medication information, importance for the patient to keep the information maintained and updated, and to share the information with other health care providers.

5. RESPONSIBILITIES:

a. Medical Center Director is responsible for assigning a Facility Medication Reconciliation point of contact and for ensuring that local policies on medication reconciliation conform to the VA Directive.

b. Chief of Staff is responsible for overall implementation and enforcement of this policy among provider staff.

c. Associate Director/Patient Care Services is responsible for overall implementation and enforcement of this policy among his/her staff.

d. Clinical Service Chiefs are responsible for completing SOPs for medication reconciliation following the guidelines set forth in this policy in each of their service areas.

e. The Nurse Manager or designee is responsible for overall implementation and enforcement of this policy among his/her staff.

f. Healthcare Team Members are responsible for compliance with this policy and clinical service SOPs on process in their clinical area.

g. QSV Service will collaborate with services during review of any medication policy/SOP reviews.

6. REFERENCES:

· Veterans Health Administration (VHA) Directive 2011-012 Medication Reconciliation, dated March 9, 2011

· VHA Directive 1164 Essential Medication Information Standards, dated June 26, 2015

· The Joint Commission National Patient Safety Goal .03.06.01

· Revised External Peer Review Process

7. RESCISSION: Numbered Memorandum 11-91-16, Medication Reconciliation, dated August 16, 2016

8. FOLLOW-UP RESPONSIBILITY: Patient Safety Manager (00QSV)

//s// J. Ronald Johnson, FACHE Medical Center Director

Distribution: All services via Outlook

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