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Medication Reconciliation Johns Hopkins Hospital March 2006 Bob Feroli, PharmD, FASHP Transition of Care Patient’s previous home medications are not considered when writing discharge orders. Patient is discharged on Zocor®(simvastatin). At home, patient starts Zocor® and continues to use previously prescribed Lipitor®(atorvastatin). Eleven days later, patient is admitted with severe rhabdomyolysis secondary to “statin” overdose. Transition of Care Patient with Parkinson's disease is admitted to an ICU for an acute episode unrelated to Parkinson’s disease. Initial care is focused on the acute episode and antiParkinson’s drugs are not used. Patient is transferred to general care unit, “Home” therapy is not considered and anti-Parkinson’s therapy is not started. Patient develops severe Parkinsonian symptoms. Transition of Care Discharge orders for 33 randomly selected ICU patients were reviewed by an RN in context with the patient’s home medications and ICU meds. Potential discrepancies were brought to the attending of the ordering physician. Discharge orders for 31 of 33 patients (94%) were changed. Pronovost P, et al. J Crit Care 18(4):201-205, 2003 Transition of Care Errors can occur when a patient’s care is passed from one group to the next Medication therapy may be inappropriately: Continued Omitted Changed Duplicated Medication Reconciliation Reassessment of medication therapy as a patient moves from one level of care to the next. When properly done will: Support continuity of care Help to avoid medication errors JHH quality improvement priority for FY06 Documentation is mandated by JCAHO Effective Jan 1, 2006 Admission Transfer Discharge Admission Transfer Discharge Admission Eclipsys SCC? Transfer Discharge Admission Transfer ICUs IMCs Adult Onc Nel-7 Eclipsys SCC? Discharge Admission Eclipsys SCC? Transfer YES Discharge Admission Eclipsys SCC? Transfer YES RN enters “home” medications into Eclipsys Discharge Admission Transfer Discharge Home Meds Eclipsys SCC? YES RN enters “home” medications into Eclipsys Rx medications Sample medications Herbal remedies Vitamins Nutriceuticals OTC drugs Admission Eclipsys SCC? Transfer YES RN enters “home” medications into Eclipsys Discharge Admission Eclipsys SCC? Transfer YES RN enters “home” medications into Eclipsys Discharge Clerical Assoc. or RN Prints Home Medication Reconciliation form Admission Eclipsys? Transfer YES Enter “home” medications into Eclipsys Discharge Print Home Medication Reconciliation form Admission Eclipsys SCC? Transfer YES RN enters “home” medications into Eclipsys Discharge Clerical Assoc. or RN Prints Home Medication Reconciliation form Admission Eclipsys SCC? No Fill out Home Medication Reconciliation form Transfer YES RN enters “home” medications into Eclipsys Discharge Clerical Assoc. or RN Prints Home Medication Reconciliation form Admission Eclipsys SCC? No Fill out Home Medication Reconciliation form Transfer Enter “home” medications into Eclipsys Discharge Print Home Medication Reconciliation form Admission Transfer Initial Med List Entered by: Eclipsys SCC? No Fill out Home Medication Reconciliation form Enter “home” medications Patient into Eclipsys Pt family member Nurse Physician Pharmacist other Discharge Print Home Medication Reconciliation form Admission Eclipsys SCC? Transfer Provides one location for the Enterhome “home” med list medications into Eclipsys Initial Screening Form H&P No Fill out Home Medication Reconciliation form “See home med reconciliation form” Discharge Print Home Medication Reconciliation form Admission Eclipsys SCC? No Fill out Home Medication Reconciliation form Transfer YES RN enters “home” medications into Eclipsys Discharge Clerical Assoc. or RN Prints Home Medication Reconciliation form Admission Eclipsys SCC? Transfer YES RN enters “home” medications into Eclipsys No Fill out Home Medication Reconciliation form Prescriber considers home med list when developing admission orders Discharge Clerical Assoc. or RN Prints Home Medication Reconciliation form Admission Eclipsys SCC? Transfer YES RN enters “home” medications into Eclipsys Discharge Clerical Assoc. or RN Prints Home Medication Reconciliation form No Fill out Home Medication Reconciliation form Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Admission Eclipsys SCC? Transfer YES Enter “home” medications into Eclipsys Discharge Print Home Medication Reconciliation form No Fill out Home Medication Reconciliation form Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Admission Eclipsys SCC? Transfer YES Enter “home” medications into Eclipsys Discharge Print Home Medication Reconciliation form No Fill out Home Medication Reconciliation form Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Place form into chart behind Med Administration tab Admission Eclipsys SCC? Transfer YES Enter “home” medications into Eclipsys Discharge Print Home Medication Reconciliation form No Fill out Home Medication Reconciliation form Prescriber considers home med list when developing admission orders Prescriber signs “Home” Medication Reconciliation form Place form into chart behind Med Administration tab Admission Transfer Discharge Admission Transfer Discharge Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Non-Eclipsys and Non-POE Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Non-Eclipsys and Non-POE Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form No-Eclipsys and No-POE Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form No-Eclipsys and No-POE Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Transfer Discharge Receiving Unit Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Prescriber Signs Transfer Reconciliation form Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber Signs Transfer Reconciliation form Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber Signs Transfer Reconciliation form Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Prescriber Signs Transfer Reconciliation form Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Place form into chart behind Med Administration tab Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber considers “Home” Med List and Meds used just prior to transfer When developing transfer orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Place form into chart behind Med Administration tab Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber considers “Home” Med List and Meds used just prior to discharge When developing discharge orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Place form into chart behind Med Administration tab Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber Signs Transfer Reconciliation form Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber Signs Transfer Reconciliation form Admission Sending Unit POE and/or Eclipsys Transfer Discharge Receiving Unit Clerical Assoc. or Nurse sends patient specific Transfer Reconciliation form Prescriber considers “Home” Med List and Meds used just prior to discharge When developing discharge orders No-Eclipsys and No-POE Prescriber Signs Transfer Reconciliation form Clerical Assoc. or Nurse sends non-patient specific Transfer Reconciliation form Place form into chart behind Med Administration tab Medication Reconciliation Next Steps Improve compliance with current system Automate reconciliation process Improve reconciliation in outpatient sector
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