S02 - SOLICITATION ATTACHMENT - D.22 Medication Reconciliation MCPM 11-146.pdf

DEPARTMENT OF VETERANS AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK AT SYRACUSE

Medical Center Professional Memorandum July 2019 Pharmacy 11-146 _

MEDICATION RECONCILIATION

I. PURPOSE:

To establish the policy and procedures for medication reconciliation in order to prevent adverse drug events associated with incomplete reconciliation of a patient’s medications as the patient proceeds through the continuum of care provided by the Medical Center.

II. POLICY:

A. Patient’s medications will be reconciled across the continuum of care in all settings, upon hospital admission, transfer, and discharge, and in the outpatient clinic settings as part of their visit.

B. Patients will be given an accurate and complete listing of their medications upon hospital discharge from the outpatient clinic settings when there has been a change in mediation therapy. This especially applies to settings when any new medication order is written, and/or medication orders are changed.

C. This process will actively involve the patient who is responsible for providing an accurate and up to date list of medications that he/she takes at home, including frequency, dosage, indication and route of administration. The patient should be involved in obtaining a list of their current home medications. If the patient is unable to provide due to impaired mental status or loss of consciousness, all efforts will be made to contact a knowledgeable family member/care giver.

III. DEFINITIONS:

A. Medication: includes any prescription medication, sample medication, herbal remedies, vitamins, supplements, nutraceuticals, over-the-counter drugs, and respiratory therapy treatments.

D.22 MCPM 11-146

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B. Minimal Medications: there are some situations that would seem to carry little risk of duplication, omission or drug interaction – things like topical fluoride in dentistry, local infiltration anesthesia for dental work or suturing lacerations, enteric barium for imaging studies. These situations typically occur as brief outpatient encounters, not involving medication use, discharge prescription of medications or any other changes in medications that the patient has been taking. For all medication use, including the

“minimal use” scenarios, a list of the patient’s current medications and a history of the patient’s allergies must be obtained. Furthermore, if all the following conditions apply, communication of the list of the patient’s current medications is not necessary:

i. The “minimal medication use” is in the context of a brief outpatient encounter;

ii. The medications in question act locally with negligible systemic effect;

iii. No other medications are used during the encounter;

iv. No new medications are prescribed for or provided to the patient for use after discharge;

v. There are no changes to the patient’s “current medications”;

vi. Any provider of care to whom the patient is being referred already has the patient’s current medication information.

C. Medication Reconciliation: Reconciliation is a process of comparing the medications that a patient/client/resident has been taking prior to the time of admission or entry to a new setting (Ambulatory Clinic, Inpatient

Hospital stay, Discharge to Home, Long Term Care, Ambulatory Surgery, Treatment/Diagnostic area, etc.) with the medications that the organization is about to provide. The purpose of reconciliation is to avoid errors of transcription, omission, duplication of therapy, drug-drug and drug-disease interactions. The process will take place in the time frame that allows improvement in the organization’s medication management process and patient safety.

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D. Level of Care: For the purposes of this policy, changes in level of care will be defined as changes in covering service (such as transfers from surgery service to medicine service or vice versa) or transfers in or out of the ICU.

E. Essential Medication Information: represents the minimal or essential elements necessary to review, manage, and communicate medication information among healthcare teams, Veterans and caregivers. This medication information is exchanged verbally, in print and via digital process and tools. See VHA Directive 1164, Essential Medication

Information Standards.

Essential Medication Information must consist of the following elements:

i. Name of drug, strength/dosage of medication, route of administration, instructions/directions for use, and notes;

ii. Sources of Medication Information

a. Local active medications

b. Remote medications

c. Non-VA Medications

iii. For the purpose of reviewing medications with patients, a list of local VA medications with the following prescription status is important in determining which mediations a patient may be taking:

a. Recently discontinued medications (90-180 days)

b. Recently expired medications (90-180 days)

c. Pending prescriptions (when relevant if patient was seen by multiple providers in the same day)

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IV. RESPONSIBILITIES:

A. Medication Reconciliation is a multidisciplinary process requiring the cooperation of a variety of healthcare workers (to include the medical staff, nursing staff, pharmacy staff and other clinical disciplines) to ensure maintenance of accurate, safe, effective, and above all, patient-centered medication information.

i. The Provider providing medical treatment or ordering medications will be responsible for obtaining an accurate medication history upon admission of a patient to the Medical Center as an inpatient, or upon presentation to an ambulatory clinic or treatment/diagnostic encounter and documenting in the medical record. The provider will be responsible for creating an accurate list of the patient’s medications.

ii. In the Outpatient Setting:

a. The provider will be responsible for creating an accurate list of the patient’s medications, reconciling the list of mediations, reviewing medication changes with the patient, documenting the reconciliation and ensuring the patient has an accurate and complete listing of medications upon completion of the patient appointment.

b. Home-Based Primary Care (HBPC) patients will primarily be the responsibility of the HBPC provider for all PACT HBPC patients (patients managed by the HBPC provider). See

Ambulatory Care and Specialty Clinics section for Tailored

Care HBPC patients.

c. All medications (including OTCs, vitamins, supplements and herbal products), from all sources will be reviewed and updated with patient/caregiver by the HBPC Provider or

Nurse at each home visit. A medication list will be left with the patient/caregiver at each home visit.

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d. If medications changes are noted during the visit, the medication list will be updated with handwritten notes.

e. HBPC nurses will alert either managing provider (HBPC

Provider or Primary Care provider) of any discrepancy to the medication list.

f. Once the medication discrepancy is reconciled and the medication list is updated by the HBPC or Primary Care

Provider, a new medication list will be delivered to the patient at the next home visit or by mail.

iii. In the Inpatient Setting:

a. The provider will be responsible for creating an accurate list of the patient’s medications.

b. The pharmacist will perform the admission medication reconciliation process and will document the admission reconciliation process in the medical record within 24 hours of admission for full ad missions, as well as for observation admissions not discharged within 24 hours of their admission. The admission medication reconciliation process will include a patient interview when possible.

c. The Inpatient pharmacist will perform medication reconciliation when patients are transferred from one level of care to another within the Medical Center and will document the transfer medication reconciliation process within the medical record.

d. The discharge pharmacist will provide the patient with their discharge medication list and medication education after the discharge medication reconciliation process has been completed.

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e. All Clinical Service Chiefs will ensure the medical staff and other providers with prescriptive privileges are educated, trained, aware of and comply with this policy.

f. All professional staff (nursing, social work, dietary, pharmacy) will be educated, trained, aware of, and comply with this policy.

g. The Chief of Staff, Associate Director for Patient/Nursing

Services and Managers/Supervisors are responsible for providing guidance and for ensuring compliance with the provisions of this policy.

V. PROCEDURES:

A. Hospital Setting Inpatient Admission/Transfer/Discharge:

i. Admission: Identifying Unreconciled Medications at Admission: The

Pharmacist will look for discrepancies in medication orders between outpatient and inpatient settings. Identified discrepancies will be communicated to the provider and documented in the patient’s medical record. Admission medication reconciliation will involve an interactive patient medication history when possible. Admission medication reconciliation will be completed within 24 hours of the patient being admitted.

ii. Documentation of the admission medication reconciliation process will include indicating (in the following or similar wording) that:

a. The medication list was reviewed with the patient/caregiver, or;

b. The patient/caregiver refused or was unable to participate in review of the medication list.

iii. Transfer: Identifying Unreconciled Medications at Transfer: Each time a patient is transferred from one level of care to another within the Medical Center the inpatient pharmacist will review medication

Pharmacy 11-146 Page 7 orders alongside new orders and/or plans for care and resolve any discrepancies. Resolution for any identified discrepancies will be communicated to the provider and documented in the patient’s

iv. Discharge: Identifying Unreconciled Medications at Discharge:

Upon identification of a patient for discharge, the discharge pharmacist will review the patient’s inpatient medications, the outpatient medications prior to admission including the prescription day’s supply and last fill date. Discrepancies will be communicated to the patient’s provider for resolution and documented in the patient’s record. Upon discharge medication counseling, the discharge pharmacist will provide a list of medications to the patient.

B. Ambulatory Care and Specialty Clinics:

i. Medication reconciliation for ambulatory care and specialty clinic patients in the clinic setting is primarily the responsibility of the provider. It includes processes to completely reconcile medications during the clinic visit and provide the patient/caregiver with an accurate list of their medications upon discharge from the clinic setting when changes in medication have occurred or if the patient does not have a medication list.

ii. If the patient is co-managed by VA and non-VA providers, the patient will be responsible for providing their VA medication list to the non-VA provider(s). Patients may be given a copy of their medication list to give to their non-VA provider(s), or they may be instructed to authorize the provision of this information to their non-

VA provider(s) through Release of Information.

iii. Medication Reconciliation will be required at each clinic visit. Upon admission to an ambulatory clinic setting, the provider will review with the patient/caregiver the medications the patient is currently taking and reconcile against the list of medications in the patient’s

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iv. A written copy of the reconciled medication list will be provided to the patient/caregiver at the completion of the clinic visit, unless:

a. The provider verifies that the patient/caregiver has their own medication list;

b. The patient/caregiver refuses a copy of the reconciled

v. Each clinic setting will determine a process to print the updated medication list from the patient’s medical record (CPRS Reports tab, Health Summary, Medication Reconciliation or templated progress note) and provide to the patient.

vi. Documentation of the medication reconciliation process will include indicating (in the following or similar wording) that:

a. The medication list was reviewed with the patient/caregiver, or;

b. The patient/caregiver refused or was unable to participate in review of the medication list, or;

c. A copy of the reconciled medication list was provided to the patient/caregiver, or;

d. A copy of the reconciled medication list was not provided to the patient/caregiver due to patient/caregiver having their own medication list or refusing a copy of the reconciled

C. Emergency Department:

i. Upon admission to the Emergency Department, the triage nurse will conduct a screening reconciliation obtaining the list of the patient’s current medications. Direct communication with the patient/ caregiver is necessary as it cannot be assumed that the list of

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Outpatient medications and the non-VA medications in the Medical

Record is correct.

ii. The ED provider will provide a focused reconciliation; reviewing with the patient/caregiver the medications the patient is currently taking and reconciling against the list of medications in the patient’s medical record (Outpatient Medication and Non-VA Medications).

iii. For patients that are to be admitted the Medical Center, a full reconciliation will be conducted as described in the inpatient admission process.

iv. Patients discharged from the ED: Documentation of the discharge medication reconciliation process will include indicating (in the following or similar wording) that a copy of the discharge medication list was provided to the patient/caregiver.

D. Specialty Treatment Care and Diagnostic Services

i. The following applies to all settings during which a planned treatment/diagnostic procedure occurs if medications are to be administered, or if the patient’s response to the treatment/diagnostic procedure could be affected by the medications the patient has been taking. This applies to both inpatients and outpatients in treatment/diagnostic settings.

ii. For procedures during which medications will be administered, a list of the patient’s current medications will be reviewed with the patient and updated by the provider. The list will be screened for potential drug interactions with any medications that will be administered during the procedure.

iii. If in post procedure additional medications are ordered for the patient, the patient will be provided with an updated list of their medications upon discharge from the procedural area to an outpatient setting.

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iv. Each setting will determine a process to print the updated medication list from the patient’s medical record (CPRS Reports tab, Health Summary, Medication Reconciliation or templated progress note) and provide to the patient.

v. Documentation of the discharge medication reconciliation process will include indicating (in the following or similar wording) that a copy of the discharge medication list was provided to the patient/caregiver.

VI. QUALITY ASSURANCE:

A. Compliance with the documentation requirements for the medication reconciliation process will be monitored through External Peer Review

Process (EPRP).

B. VHA Directive 2011-012 recommends that facilities monitor compliance as appropriate with resources being EPRP and VA Med Rec Performance

Monitor (IPEC).

VII. REFERENCES:

10N2-232-15 VISN 2 Medication Reconciliation Policy, dated November 15, 2015.

VHA Directive 2011-012 VHA Medication Reconciliation Directive, dated March

9, 2011

VHA Directive 1164 Essential Medication Information Standards, dated June 26, Joint Commission National Patient Safety Goal 03.06.01, 2012.

VIII. RECISSION:

MCPM 11-146 Medication Reconciliation dated July 2016.

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IX. REVIEW DATE:

July 2021

X. FOLLOW-UP RESPONSIBILITY:

Pharmacy 119

SYED A. ALI, MD

Chief of Staff