Section D.22 - Memorandum 011-033 Medication Reconciliation.pdf

Department of Veterans Affairs (VA) Memorandum 011-033 Central Texas Veterans Health Care System (CTVHCS) March 26, 2019 Austin-Temple-Waco Community Based Outpatient Clinics (CBOCs)

MEDICATION RECONCILIATION

1. CHANGES: 6a, 8b, 9c added reference to support staff assisting in the process;

7e physician extenders changed to mid-level provider.

2. RESCISSION: Memorandum 011-033, dated December 11, 2015.

3. NEXT REVIEW DATE: March 2022.

4. AFFECTED SERVICES: All services that prescribe and administer medications and contrast.

5. PURPOSE: The purpose of this policy is to provide a consistent process for accurately reconciling patient medications across the continuum of care at CTVHCS.

Medication reconciliation is a necessary component of a safe medication use process to avoid potential drug interactions, therapeutic duplication, unintended discontinuation, or medication-related adverse drug events.

6. POLICY:

a. The provider will perform medication reconciliation according to the guidelines below and document a complete list of the patient's current medication at every episode or transition in level of care where medications will be administered prescribed, modified, or may influence the care given. Providers will reconcile medications with the involvement of the patient, family, and/or caregiver when feasible. Support staff such as Nursing and Pharmacy can assist a provider in this process.

b. When a patient is referred or transferred within or outside of CTVHCS, the complete list of the patient's medications and the process for obtaining clarification on the list will be communicated to the next provider of service.

c. When a patient is discharged from the hospital, or at the end of the outpatient encounter, the patient and/or caregiver will be provided an updated medication list and education on medication management.

7. DEFINITIONS:

a. Medication is defined as any prescription medication, sample medication, herbal remedy, vitamin, nutraceutical, over-the-counter drug, vaccines, diagnostic and contrast agents, radioactive medication, respiratory therapy treatment, parenteral nutrition, blood derivative, intravenous solution, or any product designated by the Food and Drug Administration as a drug.

CTVHCS Memorandum 011-033 March 26, 2019

b. Medication Reconciliation is a documented review that includes comparing the medications that the patient has been taking with the medications ordered for the patient by the facility. Reconciliation should be conducted in a manner to identify and resolve discrepancies, including omissions, duplications, contraindications, unclear information, and changes. This process is completed on admission, transfer, or discharge from inpatient care and during any outpatient encounter.

c. Screening medication reconciliation: Is a documented review of the patient’s medications for allergies, potential renal complications (i.e. Metformin if using contrast), or any other potential interactions.

d. Focused medication reconciliation: Is a documented review of the patient’s medication list for allergies, adverse reactions, and any other potential interactions pertinent to the presenting medical condition and its treatment. Issues of non-compliance and potential medication interactions should also be addressed and documented.

e. Providers are defined as physicians, or mid-level providers who are credentialed to prescribe medication therapy.

8. PROCEDURES:

a. The provider will obtain information on the medications the patient is currently taking (both scheduled and as needed) when he or she is admitted to the hospital or seen in an outpatient setting. This information is documented in a list and includes VA prescriptions, non-VA prescriptions, and over the counter products. A demonstration of good faith effort to obtain this information from the patient and/or other sources is required to meet the intent of this policy. The Medication list should ideally contain the name, dose, route, frequency, and purpose of each medication.

b. The provider will compare the patient’s current medication information from available sources, (i.e. patient, caregiver, non-VA, remote VA) with patient’s current medication list in Computerized Patient Record System (CPRS) to identify and resolve discrepancies. Support staff such as Nursing and Pharmacy can assist a provider in this process.

c. Upon discharge from the hospital or at the end of an outpatient encounter, the provider will communicate with and provide education to the patient, caregiver, or family members regarding updated medication information. The provider will discuss the importance of managing medication information. The complete list of the patient’s medications and the process for obtaining clarification on the list will be provided to the patient and/or caregiver. The patient will be instructed to update the list when medications are discontinued, doses are changed, or new medications (including over the counter products) are added; and to carry medication information at all times in the event of emergency situations.

d. See Attachment for specific procedures.

9. RESPONSIBILITIES:

a. The Chief of Staff and all Clinical Service Chiefs and designees are responsible for ensuring their service providers will strictly adhere to this policy.

b. It is the responsibility of every provider to ensure that medication reconciliation is completed prior to ordering any new medications.

c. Support services such as Nursing and Pharmacy can provide assistance to the provider in medication reconciliation process.

10. REFERENCES: Current standards of The Joint Commission; VHA Directive 2011-012; VHA Directive 1164.

Medication Reconciliation. Agency for Healthcare Research and Quality. Patient Safety Primer. Aug 2018.

The Joint Commission. National Patient Safety Goals. January 2019. NPSG

03.06.01; HR.01.01.01 EP1; PC.04.02.01; MM.06.01.03; PC.02.03.01; PC.04.01.05.

/s/ Andrew T. Garcia, MHA Interim Director

Attachment

Approved by CEC: 2/19/19

ATTACHMENT

Medication Reconciliation Procedures and Documentation

1. Inpatient

a. The admitting provider will interview patient, family, and/or caregiver to obtain a list of current medications, evaluate for discrepancies, and update any changes by documenting in CPRS. The provider will typically use the history and physical note to document the admission medication reconciliation.

b. The provider will communicate relevant medication information to and between the appropriate members of the VA and non-VA healthcare team.

c. Providers will document an accurate, complete list of discharge medications in the Discharge Instructions. The discharge instructions will be given to the patient to provide a current list of their medication regimen upon discharge from the organization. Discharge education will incorporate management of medication information.

2. Non-24 Hour Settings--Outpatient (OPC) and Community Based Outpatient Clinic (CBOC) Procedures:

a. The provider will interview patient, family, and/or caregiver to obtain a list of current medications, evaluate for discrepancies and update in CPRS via order entry and medication tabs. The provider will document the medication list in a CPRS progress note. The medication list will ideally include: Name, dose, route, frequency and purpose for each medication.

b. The provider will communicate relevant medication information to the appropriate members of the VA and non-VA healthcare team.

c. An updated list of the patient’s active medication regimen will be given to the patient/caregiver after each appointment if the appointment results in a change in medication. The patient will be provided with information management of medication information.

3. Emergency Department (ED) and Urgent Care

a. The ED provider will complete a “focused” medication reconciliation based on medical relevance which may include seeking additional information about the patient’s medications (exact dose, route, frequency, and purpose).

b. Patients admitted to the facility will have medication reconciliation completed by the admitting provider as outlined above in this memorandum.

c. In urgent situations or when the resulting delay would harm the patient, immediate care takes precedence. However, as soon as possible thereafter, the provider should take steps to complete the medication reconciliation process.

4. Outpatient Surgery and areas using moderate sedation

a. On arrival medication reconciliation will be performed. Any discrepancies will be referred to the surgical and anesthesia provider.

b. The treating physician will look at the pre-operative medication list and determine which medications should be ordered and/or continued post-operatively.

c. Upon discharge, the patient will be provided with an updated list of medications and appropriate education related to medication management.

5. Imaging, Dental, and others not addressed above

a. For situations in which medications will not be administered or prescribed, or only a local anesthetic or contrast is used, a “screening medication reconciliation” will be documented.

b. When ordering medications or performing procedures involving the use of pharmaceuticals, documentation of a full medication reconciliation is required.