Download Technician Education Session for MedRec

MEDICATION RECONCILIATION
BPMH Training Guide
A. Background Information on Medication Reconciliation
1. Definition and Purpose of Medication Reconciliation
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A formal process of obtaining the Best Possible Medication History (BPMH) and reconciling
discrepancies to facilitate safe pharmaceutical care for patients at admission, transfer and
discharge.
Medication Reconciliation is a 3-step process consisting of:
1. Creating the most complete and accurate list possible of all home medication for each patient
2. Using that list when writing medication orders
3. Comparing the list against the physician’s admission, transfer, and/or discharge orders, identifying
and bringing any discrepancies to the attention of the physician and if appropriate, making changes to
the orders
Refer to handout p.7-9 from Safer Healthcare Now! Getting Started Kit,
Website www.saferhealthcarenow.ca
2. Why is it important to identify all of the patient’s home medications?
 Continue medications for their illnesses while in hospital.
 Patient may be experiencing adverse effects from their home medications leading to visit to
hospital.
 Some medications, if not continued in hospital, may lead to withdrawal symptoms.
 Procedures may not be done safely if patient has been taking certain drugs (e.g. Blood thinners).
 For surgical tests or procedures, need to give patient instructions on medications to be continued
up to surgery or stopped prior to surgery – if not done, can result in complications during or after
surgery.
 At discharge, need to communicate to patient, family doctor, community pharmacist about meds
that have been added, changed, or stopped during hospital stay.
3. Why is Medication Reconciliation so important?
 Patient Safety- reduces adverse drug events.
 One of 6 patient safety initiatives part of Institute for Healthcare Improvement (IHI) and Safer
Healthcare Now! Campaigns.
 Canadian Council on Health Services Accreditation (CCHSA) statement on Patient Safety Goals
and Required Organization Practices for 2005.
 One element of “Seamless Care” identified by Canadian Society of Hospital Pharmacists (CSHP)
and Canadian Pharmacists Association (CPhA).
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4. Why is there a problem identifying the patient’s home medications?
 Lack of awareness of patients - importance of knowing the names, doses and frequency of the
medications they are taking, or patient may not be able to provide list due to condition.
 Multiple incomplete and conflicting home medication lists on most patient charts.
 No identifiable place to document and file patient’s home medications.
 No single person accountable for ensuring the list is complete and accurate within a specified
timeframe.
 Lack of communication with patient/family regarding how the patient is actually taking the
medication.
 No process for communicating and correcting discrepancies.
B. Taking a Best Possible Medication History
Concept of “Best Possible Medication History” – What is it?
 A medication history obtained by a pharmacist or delegated to certified healthcare staff, that
includes a thorough history of all regular medication use (prescription or non-prescription) using
some or all of the following sources of information:
o patient or caregiver interview
o inspection of prescription vials
o follow-up or list of current medications printed from a community pharmacy.
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“Best possible” may not be perfect – there are time constraints.
Strong evidence supports expertise of pharmacists/pharmacy technicians in collecting accurate
histories (Massachusetts Coalition For the Prevention Of Medical Errors).
Recent study (American Journal of Health System Pharmacy, Dec. 15/06) compared medication
histories in the Emergency Department collected by ED providers (physicians, nurses, medical
students) vs. clinical pharmacists.
o In the study, in 252 medication histories, clinical pharmacists identified 1096 home
medications vs. 817 home medications documented by ED providers (non-prescription
medication and dietary supplements not included).
o Of the 817 home medications identified by the ED providers, 637 (78%) were incomplete
and were supplemented by dosing information from the pharmacists.
o A structured form was used to guide the interview and record the answers.
The medication list reflects how the patient is actually taking the medication, which is often
different from the directions indicated on the vial, pharmacy list, etc. Patients may independently
decide to change how they are taking the medication, or the physician may have told them to
change the directions, but this is not reflected on the prescription vial.
Sources of information that can be used:
o Prescription labels and containers.
o Patient’s own list.
o Ontario Drug Benefit (ODB) computerized list (available from DPV)
o List of medications filled by the patient’s community pharmacy (fax or print-out carried
by the patient) (Profile or MedsCheck).
o Patient Questionnaire completed prior to Surgery by Patient.
o MAR from another hospital or nursing home.
o Medication Lists from other health professionals (Physicians, Paramedics, etc).
o Family Physician.
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1. How to Structure Interview to obtain a complete list of patient’s home medications
Introduction to Patient Interviewing: Communication Skills
Opening of Interview:
o Introduction
o Obtain Consent
o Establish Goals of the Interview
o Establish Patient Comfort
Example:
Hello Mrs. Smith, I’m Robyn the Pharmacy Technician working in the Emergency Department. My role
is to find out about all the medications that you have been taking at home so we have a most complete
list. Is it all right if I spend 10-15 minutes going through your home medications with you? How are you
feeling right now?
2. Interviewing Techniques to Use to Obtain Best Possible Medication History:
1. Use a balance of open-ended questions (what, how, why, when) and yes/no questions.
2. Use nonbiased questions that do not lead the patient into answering something that may not be
true (e.g. you do take this medication as prescribed, right?)
3. Pursue unclear questions until they are clarified – do not assume.
4. Ask simple questions, do not medical jargon (e.g. PRN, bid), and always invite the patient to ask
questions.
Let the patient know the importance of using one central pharmacy/pharmacist, in order to have an up-to
date medications list.
Actual Interview
1. Identify patient using 2 identifiers (e.g. name and wristband, etc).
2. Introduce yourself, explain reason for interview, and obtain verbal consent from patient.
3. Ask if patient has prescription vials or a list of their medication with them.
4. Ask patient to describe how much and how often they are taking each medication, for when needed
(PRN) medications ask if they are taking it regularly or only once in a while (ask when last dose was
taken).
For each medication obtain and record name, dosage form, dose and dosing frequency.
5. Inspect contents of prescription vial to assess if the patient may have mixed different medication(s)
in the vial.
6. Use other sources of information when vials/list are not available or to supplement information from
patient.
7. Ask about all medications:
o Prescribed by Doctor
o Not Prescribed by Doctor
o Over the Counter (OTC) (including daily ASA 81mg (‘baby aspirin’))
o Herbal/Alternative/Traditional Medicines
o Vitamins/Supplements
o Potassium Supplements
o Prompt the patient about other dosage forms – try a ‘head to toe’ approach – e.g.
medicated ointments, creams, eye or ear drops, sprays, puffers, patches, injections,
samples.
o Medications that are only being taken when needed (e.g. Advil, Tylenol)
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8. Ask if there been any medication changes recently – stopping, starting, or dose changes (e.g.
Did the doctor change the dose or stop any of your medications recently? Have you changed the
dose or stopped any of your medications recently?)
9. Ask the patient if they go to more than one community pharmacy.
10. Allergies:
Ask the following: What medications are you allergic to? What did you experience the last time you
took it (e.g. Rash, trouble breathing)?
Complicated Situations
o If encountering difficulty with certain situations, seek assistance from the Pharmacist or Nurse.
Closing the Interview:
o Explain the next steps in the process (e.g. what happens next).
o Thank the patient for their time
Example:
I am going to pass on the information about your home medications to the nurse and the pharmacist.
They may have some further questions for you about your medications. Then your physician will review
your home medications to see if any changes need to be made to your medications in hospital.
Thank you for your time and attention.
Note: we are looking for BEST POSSIBLE medication list, and despite our best efforts this may not be
PERFECT, the average amount of time per patient should be 15-20 minutes.
3. Communication/Referral to a Pharmacist or Nurse, or Physician
Issues raised by the patient during the interview that must be communicated to the Pharmacist or Nurse
for their assessment are those that are not in the scope of practice of a Pharmacy Technician. These
include:
 Clinical questions (e.g. Is this really the best medication for my condition? Can I take something
else instead?)
 Questions requiring interpretation
 Issues relating to the compliance (adherence) of the patient to their medication regimen (e.g. I
don’t take this every day, it gives me a terrible upset stomach – is that OK? Or I don’t take my
water pills because I don’t feel like I have any problems – is that right?)
Refer to the Pharmacist if experiencing difficulty communicating with the patient/family (language
barriers, confused) or experiencing difficulty with challenging patients (e.g. dementia, very angry/upset,
mental health or other issues).
C. Review of Sources of Information
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Prescription Vials:
Check name of patient (!!)
Check fill date on the vial to ensure the medication is current.
Check to see if any evidence that contents of vial do not match the name of the medication on the
vial.
2. Ontario Drug Benefit (ODB) List
 List of medications that have been billed by Community Pharmacies to ODB can be printed.
 Ontario Drug Benefit eligible patients are seniors (65 years of age or older), welfare, social
assistance, home care, Trillium Drug Plan
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ER Registration Clerk is supposed to print out the form but sometimes this does not get done or
is lost.
The list only includes medications that are covered by the ODB plan and does not provide the
dosing frequency, but does supply the quantity and the “estimated days supply”.
Can obtain the community pharmacy name/phone number and physician name/phone number
from the list.
Community Pharmacy Records
Phone community pharmacy to obtain record of prescriptions filled.
Best to ask for faxed copy so that the Nurse or Pharmacist can review it.
Community pharmacist often asks for Date of Birth of the patient for confidentiality purposes,
occasionally may ask patient to provide verbal consent.
According to the OCP article about privacy legislation, the “circle of care” in a hospital includes
attending physician and the healthcare team who have direct responsibilities of providing care to
the individual (this includes Pharmacy Technicians).
No standard format for community pharmacy dispensing records, depends on computer system
being used by the pharmacy.
Unlike ODB record, they do provide the dosing frequency for the medication.
4. Family Physician
 Some family physicians keep updated record of the patient’s medication.
 Suggest using the Community Pharmacy first as all have computer records, but the family
physician might be useful if patient going to multiple Pharmacies.
5. Medication and Admission Record (MAR) from institutions (nursing home, hospital, etc)
 Reliable source of information on all medications patient is receiving in institution.
 However, if patient came to the other hospital from home, may not have clear record of their
home medications.
6. Patient Questionnaire
 Patients who are having surgery are asked to complete the medication section of the patient
questionnaire as part of their surgical package.
7. ER Record Form
 Prior to patient being admitted from ER, medications are documented on the ER record, in the
small shaded box on the form.
 Not always documented with dose and frequency, sometimes just the name of the medication,
but may be a “starting point” especially if the prescription vials have been sent home.
D. Putting it All Together: Documentation and Step-by-step Procedure
Thorough and consistent documentation is a requirement whenever completing any task, especially a
BPMH. Refer to separate procedures attached for the complete process.
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Reference:
Patient Interview, University of Toronto Pharm D Program
Verbal Communication Techniques
Complicated Patients
Cases to illustrate collection and documentation of patient’s medication history and reconciliation with
admission orders.
Adopted from the Trillium Hospital Technician Certification for Medication Reconciliation.
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