S02 Attachment Fifteen 15 Medical Care Memorandum Number 548 99 246 Medication Reconcilliation.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER MEMORANDUM

MEDICAL CENTER NUMBER: 548-99-246

WEST PALM BEACH, FLORIDA March 14, 2019

MEDICATION RECONCILIATION ACROSS THE CONTINUUM OF CARE

1. PURPOSE: To establish policy and procedures for an accurate and complete reconciliation of patient’s medications across the continuum of care.

2. DEFINITIONS:

A. Medications: Medications include any prescription medications; sample medications; herbal remedies; vitamins;

nutraceuticals; over-the-counter drugs; vaccines; diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions;

radioactive medications; respiratory therapy treatments;

parenteral nutrition; blood derivatives; intravenous solutions (plain, with electrolytes and/or drugs), and any product designated by the Food and Drug Administration (FDA) as a drug.

The medication reconciliation process will be appropriately documented in the patient’s chart in CPRS.

B. Medication Reconciliation: Medication Reconciliation refers to the process of obtaining, comparing, and updating a patient’s current medication(s) usage to the patient’s medication profile in CPRS.

C. 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.

D. Medication Discrepancy: Medication discrepancies are unintentional differences found in the patient’s medication information when compared to the medication information available in CPRS. These discrepancies may include but are not limited to errors of transcription, omissions, inappropriate duplication, changes, and/or addition of medications. These discrepancies may be generated from the patient or the health care system.

E. Non-VA Medications: Non-VA medications refer to medications prescribed by a non-VA or VA provider filled at non- VA pharmacies or remote VA medications. It also includes herbals, over-the-counter medications, nutraceuticals, and alternative medications.

F. Provider: VA providers are physicians, nurse practitioners, physician assistants, clinical pharmacy specialists, dentists, and podiatrists.

Attachment Fifteen (15)

36C24821R0092

3. POLICY: The medication reconciliation process ensures the maintenance of accurate, safe, effective, and patient centered medication information by: a) obtaining medication information from the patient, caregiver, or family members b) comparing this information to medication information available in Computerized Patient Record System (CPRS) in order to identify and address discrepancies c) updating the medications in the outpatient order entry and non-VA medication section of CPRS and d) communicating to the next provider of service when the patient is referred or transferred to another setting, service, practitioner, or level of care within or outside of the organization.

4. PROCESS:

A. Medication reconciliation is a multidisciplinary process. All disciplines involved in the patient’s care are responsible for reconciling medications across the continuum.

B. Patient Care Services will be knowledgeable of the medication reconciliation process and collaborate with pharmacy and/or the reconciling provider.

C. Outpatient Process

1) Outpatient setting includes Primary Care, Mental health, as well as Specialty Areas.

2) Outpatient medication reconciliation will be as followed:

a. At check-in, the Medical Administrative

Service (MAS) staff will print out and provide to the patient their current medication list to review prior to their scheduled appointment.

b. The provider will print a current medication list if MAS is not available.

c. The nurse will ask the patient to write any additions/changes/deletions on the paper list. The list is returned to the patient for the provider to review. The nurse will remind the patient of the sensitive information and to not just discard the list. This will not be required if the provider prints the current medication list if MAS is not available.

d. Health care providers with prescriptive authority are ultimately responsible for correcting discrepancies and updating the patient’s medication profile and non-VA medication list in the VA electronic medical record.

e. Providers are responsible for assuring that patient(s) and/or caregivers receive a current, accurate and complete mediation list upon each new encounter where medication changes occur. Providers will remind patients and/or caregivers to discard old medication lists.

f. Providers will encourage patients and/or caregivers to take ownership of the current medication information provided and encourage them to actively participate in the decision making of the treatment plan.

g. Providers will update the medication list to include new medications. Providers will certify that medication education and counseling for newly prescribed medication has been tailored to the patient and/or caregivers needs by outlining why the medication was prescribed, how they should take it, how long they will take it, what to expect from it and what happens if they do not take the medication as prescribed.

h. The outpatient medication list is reconciled by:

1. Obtaining an accurate list of the patient’s current medications, including dose, route, and frequency. This should be done to the best of the provider’s ability.

2. Comparing the information obtained from the patient and or caregiver to the medication information available in the VA electronic medical record, including active medications, recently expired medications, medications given at other VA facilities and non-VA medications, in order to identify and address discrepancies.

3. Discontinuing unnecessary or inappropriate medications.

4. Ordering new medications and noting any dosing or schedule changes.

5. Renewing medications which have expired since the prior visit or that will expire prior to next planned visit as appropriate.

6. Updating drug allergies/adverse drug events on the patient’s coversheet.

7. Updating non-VA medication list. If the patient is not taking any non-VA medications, entering this is the non-VA medication list.

8. Documenting medication changes in detail within the treatment plan of the progress note.

9. Resolving any identified discrepancies between what the patient is taking and what has been prescribed and documenting the presence or absence of medication discrepancies.

10. If it becomes clear that patient’s medications need more extensive review, the provider may enter a consult for a clinic pharmacy specialist to review medications with patient.

11. If significant or critical drug interactions are found the provider may contact a pharmacist immediately for assistance in resolving the interaction.

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

Medication information includes name of medication, dose, route, frequency and indication/purpose.

3) A clinical pharmacy specialist (CPS) in primary care will attempt to contact all new patients prior to their initial primary care provider appointment. The CPS will call the patient and generate a medication reconciliation note in CPRS listing the patient’s current medications which will include prescription and non-prescription medications. Non-prescription medications such as over-the-counter and herbal medications will be entered the non-VA medication list. If the patient is currently taking non-formulary medication(s) then alternative choices will be provided in the medication reconciliation note.

In addition, the CPS will enter any adverse drug reactions/allergies in the patient’s cover sheet. The CPS informs the patient to bring their medication or medication list for further review by the primary care provider at his/her upcoming primary appointment. All prescription medications to be dispensed from the VA will be ordered and updated by the primary care provider in CPRS.

D. Inpatient Process

1) Patients are admitted into the facility through the Emergency Department, by direct admission to the floor, or during an outpatient visit.

2) Provider will obtain, compare, and “reconciles” the medication list including dose, route, and frequency from the patient, caregiver, or family members to ensure accuracy. This includes active medications, recently expired medications, medications given at other VA facilities, and non-VA medications to identify and address discrepancies.

3) Provider will obtain, compare, and reconcile the medication list including dose, route, and frequency from the patient, caregiver, or family members to ensure accuracy. This includes active medications, recently expired medications, medications given at other VA facilities, and non-VA medications to identify and address discrepancies.

4) This list should be completed before any new medications are ordered. In the event of an emergent condition, unresponsive patient, severely demented patient without a caregiver, etc. the provider may decide based on the relative risk to the patient, whether to wait until the process can be completed or to order the medications and perform the reconciliation when circumstances permit. The provider shall make this decision taking into consideration, the patient’s current condition and care needs. At a minimum the list must be completed within 24 hours. Providers will make an effort to expeditiously obtain information on any patients taking high-risk medications, such as insulin, narcotics/opiates, or anticoagulants (refer to High-Alert Medications in Forms Navigator). If a patient resides at a Community Nursing Home or Assisted Living Facility, the provider will obtain the Medication Administration Record (MAR) from that facility.

5) A medication reconciliation pharmacy consult may be utilized to obtain pharmacy services. Once consulted, an acute care CPS will provide a thorough medication reconciliation of the patient’s chart and document recommendations in CPRS for the provider’s review.

6) Whenever a patient is transferred to a different level of care, new orders are placed, or orders are re-written, the reconciliation process will occur. The transfers are upon admission, to or from different clinical services, to or from ICU care, and to or from Long Term Care. The correct list of the patient’s medications is communicated to the next provider of care. The new provider of record at the accepting service is responsible to document that the medication reconciliation process occurs.

7) Prior to planned discharge, the provider will complete the following PRIOR to initiating the Discharge Note/patient Instructions template:

a. Reconcile, review, compare and update the current inpatient and outpatient medications to reflect the correct list.

b. Resolve any identified discrepancies between what the patient is taking and what has been prescribed and documenting the presence or absence of medication discrepancies.

c. Discontinue unnecessary or obsolete outpatient medications.

d. Order new medications in the outpatient profile and/or non-VA.

e. Update outpatient profile and/or non-va medication section as needed (e.g. change in dosage or frequency)

f. Renew outpatient medication orders as necessary.

8) Initiate Discharge Note/Patient Instructions and document all medication changes in the treatment plan of the progress notes.

9) Provider will discuss and provide written documentation to the patient/family/caregiver regarding any newly prescribed medication by outlining why the medication was prescribed as well as medication changes. Provider will remind patient/family/caregiver to discard old lists.

10) Final medication list is included in the Discharge Note/Patient Instructions and printed by nursing upon discharge.

11) If a patient is discharged or transferred to another facility or known provider of care, the attending physician or provider will write for the discharge or transfer orders. A complete list of current medications is given to the next provider of care and/or to the patient.

E. An Imaging Technologist will screen all patients requiring administration of contrast to ensure there are no known allergies to IV nonionic iodinated contrast media. The Imaging Technologist will also conduct a review of the patient’s medication to determine if the patient is prescribed metformin or a combination product containing metformin. If it is determined that a patient is taking metformin or a combination product containing metformin, the metformin follow-up protocol will be initiated through CPRS consult. The Radiologist will be responsible for establishing standardized protocols and providing clinical guidance in the event a potential medication interaction is identified, outside the set protocols.

5. RESPONSIBILITY:

A. Chief of Staff is responsible for ensuring all providers are in compliance of this policy, including:

1) Completing and documenting thorough medication reconciliation in CPRS for every appointment, admission, and discharge.

2) Updating patient’s medication profile to include new medications, changes to medications, and discontinuations of medications. This must be accurately relayed to the next provider of care should a transfer of service occur.

3) Assuring that patients and/or caregivers receive a current, accurate, and complete medication list upon each new encounter where medication changes occur.

B. Chief, Pharmacy Services is responsible for ensuring all medication reconciliation requests and consults are responded in a timely manner. A designated pharmacist will provide and document medication reconciliation and suggestions in the patient’s chart within CPRS.

C. Chief, Medical Administrative Service will ensure MAS staff provide a current list of patient’s medications prior to patient’s scheduled outpatient appointment.

D. Associate Director, Patient Care Services will ensure nursing staff is knowledgeable of the medication reconciliation process and collaborate with the reconciling provider and/or pharmacist.

6. REPORTING STRUCTURE: N/A

7. REFERENCE:

A. VHA Directive 2011-012. Medication Reconciliation, March 9, B. The Joint Commission National Patient Safety Goals, Goal#3.

8. FOLLOW-UP RESPONSIBILITY: Patient Safety Manager (99)

9. RESCISSION: MCM 548-99-246, dated November 1, 2015

10. RECERTIFICATION DATE: March 14, 2022

Donna Katen-Bahensky Medical Center Director

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER MEMORANDUM

MEDICAL CENTER NUMBER: 548-99-246

WEST PALM BEACH, FLORIDA NOVEMBER 1, 2015

ATTACHMENT A

PATIENT CARE SERVICES PARTICIPATION IN MEDICATION RECONCILIATION

PURPOSE:

Because medication reconciliation is often confusing to the patient, interdisciplinary approaches to meeting this requirement are necessary. The process supplies team members with a complete pharmacologic picture of the patient’s status.

This standard operating procedure (SOP) will help define the individual areas supported by patient care services and responsibilities where support to the medication reconciliation process occurs. If the patient has difficulty reading or seeing for any reason, the nurse will assist with reading the list.

When the patient is unable to provide this information, the medications will be obtained from family members, caregivers, outside Providers and Pharmacists, as feasible.

BACKGROUND:

The West Palm Beach VA Medical Center and its outpatient clinics’ policy is to implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization with the involvement of the patient. A complete list of the patient’s medication is communicated to the next Provider of service when the patient is referred or transferred to another setting, service, practitioner, or level of care within or outside of the organization. The list of medications obtained at entry should include only what the patient is currently taking.

Process for Medication Reconciliation based on location:

Emergency Room/Acute Care/Dialysis:

Emergency Room

• Medication reconciliation will take place on each patient visit to the ER

• The MAS clerk will print out a medication list and place it in the bin for the triage nurse to gather prior to calling in the patient for the triage process. MAS will also provide an envelope to the patient to keep the list in after they have received it from the Triage Nurse.

• The ED triage nurse will triage the patient then hand the patient this CPRS medication list and inform the patient of the need to carefully review it. He/she will instruct the patient to make notations on the paper for any updates or changes including over the counter medications and herbal supplements The patient will be instructed to keep the list in the envelope provided to give to the physician. The ED triage nurse will advise the patient that this list has Protected Information and not discard this list for their own personal protection.

• The ED triage nurse will advise the patient to review this list with the ED physician AND to maintain this list in their possession to review with all care providers.

• The ED physician will review the list with the patient and annotate any discrepancies in the Medication Reconciliation area of the emergency department EMR; if discrepancies exist, the ED physician will either change the item on list or add primary care clinician as an additional signer on the ED note.

• ED physician will return list to patient.

In-Patient Acute Care

• Medication reconciliation takes place upon admission and whenever the patient moves between different services, to or from ICU care, and to or from Long Term Care.

• When the RN administers medication, the nurse will take the opportunity to answer any questions regarding medications that the patient may have.

• Any patient leaving the floor for a diagnostic test or other care that cannot be provided on the ward (e.g. dental, eye) does not require an additional medication reconciliation process. The physician or other Licensed Independent Practitioner is responsible to ensure that any potential reactions are reviewed at the time the order is placed.

Dialysis

• On the first visit and monthly thereafter, the Dialysis RN and/or provider requests the patient to bring in all medications they are currently taking. Electronic medication reconciliation is completed by the provider during patient rounds.

• Dialysis RN re-enforces provider instruction and provides additional information/handout on all newly prescribed medications. Additional handouts are also provided for all other medications upon request of the veteran.

• Dialysis clerk or nurse provides the patient with a current list of CPRS medications on the first visit of each calendar month.

• If a patient needs a refill, providers will be notified when renewals are necessary through the standard dialysis communication process.

• Patient compliance to prescribed medications will be noted under functional observation in the monthly interdisciplinary notes completed by the patient’s primary nurse.

• On admission to SSU, nursing staff will confirm medications adjustments, made for the purposes of surgery by reviewing the current medication reconciliation sheet with patient. Notations regarding held medication will be made by patient, with assistance as needed, and notated reconciliation sheet will be added to the pre-op paper folder to travel with the patient to the OR suite for the surgeon’s review.

Long Term Care/Community Living Center (CLC):

• Medication reconciliation occurs during admission or re-admission and once per month thereafter. The CLC Licensed Independent Practitioner will document a note that all medications were reviewed with the patient, and to ensure that other herbals or over the counter medications that may have been brought by family are recorded.

Home Based Primary Care:

• On the initial visit the provider asks the patient to bring out all of his/her medication bottles to review. The provider reconciles the bottles with the medication list from CPRS and documents the process in the progress note for the home care visit.

• Once per quarter at a home visit the process is repeated.

• For patients in an Assisted Living Facility (ALF), a VA pharmacist compares the medication administration documentation from the facility to our CPRS medication list. Discrepancies are discussed with the patient, the provider, or the facility as appropriate. A note is places in CPRS.

Diagnostic Services for Outpatients only:

• The provider reading the test is responsible for ensuring that the medication reconciliation process is completed prior to the administration of any drugs or biological for the examination.