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
• Medication Reconciliation impacts on resident safety
Transitions in 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
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
• Interviewer’s skill level
• Time constraints
• Accuracy and completeness of medication histories
obtained from other resources
• Accessibility of resident’s medication list during
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
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
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
• 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
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.
9.Investigate resident’s medication compliance.
1.Obtain a detailed description of the medication from the
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
• 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.
• 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
• 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