Presentation to introduce MedRec to LTC nursing staff

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					     Medication Reconciliation:
Opportunity to Improve Resident Safety

Overview and Objectives

  Following this session you will gain an understanding of
  • To conduct a medication reconciliation on all new
    admissions and readmissions to long term care,
  • To obtain a best possible medication history on each
    new resident
  • Medication Reconciliation impacts on resident safety
Transitions in Care

                      Acute Care

                                   Ambulatory Care
Home Care         Long Term Care

•   The potential for medication errors and resident harm
    exists if medication histories are inaccurate and/or
    incomplete and are subsequently used to generate the
    resident's medication orders
•   Lack of knowledge of resident’s medications at transition
    points (admission, transfer, discharge) is believed to be a
    key source of adverse events
                           –   Massachusetts Coalition for the Prevention of Medical Errors
Medication Reconciliation in Long Term Care

         Safer Health Care Now Video
What is Medication Reconciliation?

• Process of collecting and documenting complete medication and
  allergy histories from the resident and/or family.
• Process of comparing and deciding which medications should
  be continued, held, or discontinued on admission and at
• Includes communication between health care providers.
• Includes a commitment to review all medications at time of
  admission, transfers, and/or discharge.
• Intended to minimize potential harm from unintended
• Timely process but well worth the time spent ~ leads to better
  resident outcomes.
What is Medication Reconciliation?

•   Occurs at transitions and interfaces of care
•   Indentifying discrepancies
•   Resolving discrepancies
•   Preventing adverse drug events by:
    – Eliminating undocumented intentional discrepancies
    – Eliminating all unintentional discrepancies
What is the Goal of Medication Reconciliation

• Eliminate unintentional discrepancies
• Decrease medication related adverse events
• Improve client safety
    Why Perform Medication Reconciliation?

•   Rate of medication errors in a 6 month period decreased by 70%
    after implementation of a medication reconciliation process at all
    phases of hospitalization - Rozich J.D. & Resar R. JCOM. 2001; 8: 27-34
•   Pharmacist participation on medical rounds and reconciliation and
    verification of patient medication profiles at interfaces of care greatly
    reduced medication errors - Scarsi, K et al. Am J Health-Syst Pharm. 2002; 59:

•   One study found 94% of the patients had orders changed after an
    ICU stay. By reconciling all pre-hospital, ICU and discharge
    medication orders, nearly all medication errors in discharge
    prescribing were avoided - Provonost P, et al. Journal of Critical Care. 2003;

• Resident and/or advocates ability to recall medications,
  doses and/or frequency of use
• Stress of transitioning through the healthcare system
• Health Literacy
• Language barriers; cultural beliefs
• Relationship with the healthcare clinician who is obtaining
  the history

• Interviewer’s skill level
• Time constraints
• Accuracy and completeness of medication histories
  obtained from other resources
• Accessibility of resident’s medication list during
  night/weekend hours
Sources of Information from Another LTCF or

• Previous 24-hours MAR
• Medication Profile
• Resident Assessment instrument (RAI) –
  standard screening/assessment tool LTC
• Pre-LTC/Hospital Medications
Steps to Conducting a Medication Reconciliation

Four Steps:

  1.   Obtaining the Best Possible Medication History (BPMH)

  2.   Identifying discrepancies

  3.   Reconciling discrepancies

  4.   Spreading processes to other transitions of care
Step 1. Collect an Accurate Allergy and
Medication History

 Collect an Accurate Allergy and Medication History

 • Taking a complete allergy and medication history is an essential
   step toward ensuring resident safety.

 • The risk of preventable adverse medication events can be
   significantly decreased by knowing the complete medical history.
What is Defined as a Medication?

•   Prescription medications          •   Blood derivatives
•   Implanted pumps,                  •   Intravenous solutions (plain or with
•   Narcotics, etc                        additives)
•   Sample medications                •   Any product designated as a drug
•   Vitamins                          •   Diagnostic and contrast agents
•   Nutriceuticals
•   Over-the-counter
•   Radioactive medications
•   Respiratory-related medications
•   Parenteral nutrition
Overlooked and Easy to Forget Medications

•   Implanted pumps        •   Narcotic Patches
•   Eye drops              •   Over-The-Counter
•   Nasal sprays           •   Samples
•   Vitamins               •   Dental medications
•   Herbals                •   Inhalers
•   Homeopathic remedies   •   Dietary supplements
•   Creams
Interviewing the Resident and / or family member

1.Ask about medications
2.Use open-ended questions.
3.Use nonbiased questions.
4.Pursue unclear answers.
5.Ask simple questions.
6.Review medications brought to the home on admission.
7.Prompt the resident/family for other medications.
8.Discuss allergies.
9.Investigate resident’s medication compliance.
Seeking Clarification

1.Obtain a detailed description of the medication from the
  resident/family .
2.Talk to any family members present or contact someone
3.Ask the pharmacist to call the resident’s pharmacy.
4.Contact the resident’s physician(s).
5.Obtain previous medical records and compare this with the
  admission orders.
Interviewing Strategies

•   Introduce yourself
•   Use open-ended questions
•   Pursue unclear information until it is clarified
•   Review any med wallet cards carrying by the resident or any list
    of meds brought with them.
Interviewing Strategies

• Don’t accept med lists without verifying the information with the
  resident, and/or caregiver
• Link medications to conditions
• Assess resident’s compliance by asking questions such as:
   – How do you take your medications?
   – Are there any medications that you have stopped taking?
   – Why did you stop them?
Additional Questions to Ask

• What does the tablet you are taking look like?
• What medication do you take for your heart problem?
• Are there medications that you take only sometimes
  or when you need them? How often do you take it?
• When was the last time you took it?
• Does your doctor give you any sample medications to
Sample Medication History Questions

• Let’s look at yesterday. Starting from when you woke, what was
  the first medication you took?

   – How many times a day did you take it?
   – What are you taking it for?
   – What other medications did you take?
What Information is Necessary about the

 •   Medication Name
 •   Dose (mg, tab, etc.)
 •   Route of Administration
 •   Frequency (How often?)
 •   What time of the day?
 •   When did you most recently take the medication - (date/time)
 •   Reasons for the medications
Sample Allergy History Questions

• What medication allergies or adverse drug reactions do you
• Educate the resident/family about the difference:
   – True Allergies cause reactions such as a rash, bronchospasm, itching, etc.
   – Adverse Drug Reactions are the patient’s response to the drug such as
     nausea, dry mouth, etc.
• What was the medication?
• When did this happen?
• What other types of allergies do you have; food, environmental?
Step 2. Identifying Discrepancies

• Cross check the admission orders against:
   – Previous MAR from discharging facility – specifically most
     recent medications given
   – CCAC MDS assessment forms – checking through all pages
     for any handwritten notes
   – Any previous orders/MARS, if a readmission
   – List of medications from resident/family
Identifying Discrepancies

• Refer to the arrival list when writing medication orders for
  admission, transfer, and discharge.
• Compare the arrival list with every medication ordered at
  admission or discharge and look for discrepancies
• Address ALL discrepancies with the physician
Step 3. Reconciling Discrepancies

Share the List
• Upon admission/readmission, inform physician and pharmacist
  of any discrepancies
• Document any discrepancy in the admission progress notes
• When transferring, or discharging the resident to an outside
  facility, remember to provide:
   – A copy of the most recent MAR.
   – A copy of the transfer record.
• Discuss the discharge instructions with the resident and/or
Step 4: Process Changes for Medication

 • Establish the expectation that residents come with all their
   medications upon admission.
 • Improve access to complete medication lists at admission,
   readmission, transfer and discharge.
Types of Medication Reconciliation Errors

•   Improper dose/quantity   • Extra dose
•   Omission error           • Wrong resident
•   Prescribing error        • Mislabeling
•   Wrong drug               • Wrong administration
•   Wrong time                 technique
                             • Wrong dosage form
                                     Medmarx® reporting program
When do you Conduct a Medication

 At all transfer
 points of care


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