Download Med Rec 1 Orientation - Communities of Practice

A formal process of obtaining a
complete and accurate list of each
patient’s current medications
At
Admission, Discharge
and at all other
Transitions in Care
• Chart reviews have revealed over half of
all hospital medication errors occur at the
interfaces of care
• Medication errors are one of the leading
causes of injury to hospital patients
• 2004 Canadian Adverse Events Study
– Drug and fluid related events were the second
most common type of procedure or event to which
adverse events were related
• 2004 Study in Canadian Hospital
– 23% incidence of adverse events in patients
discharged from an internal medicine service
• 72% were medication related
• 2005 Canadian Study
– 151 General Medicine patients
• Prescribed or receiving at least four medications
• Not from an extended care facility
– 53.6% - Patients  1 Unintentional Discrepancy
• 38.6% - Potential to cause moderate or severe
discomfort or clinical deterioration
• 46.4% - Omission of regularly used medication
• Canadian Council on Health Services
Accreditation
– Patient Safety Goals & Required Organization
Practices for 2005
• “Reconcile the patients’ medications upon admission, and
with the involvement of the patient”
• “Reconcile medications with the patient at referral or transfer
and communicate the patients’ medications to the next
provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization”
• “Desirable continuity of care delivered to a patient in the health
care system across the spectrum of caregivers and their
environment”
• “When moving between levels of care, patients’ drug information
is not always transferred to all care providers in a timely fashion…
consequently, the patient may not receive the most appropriate
regimen for their condition of this seamless care process”
Medication Reconciliation
is a key component of the Seamless Care process
Easy as 1-2-3
1. Create the most complete and accurate list
possible of all current medications
2. Use this list when writing medication orders
3. If using this process after admission orders
have been written, reconcile and resolve
any discrepancies
An accurate medication
history is performed prior
to physician admission
order writing
An accurate medication history
is performed after physician
admission order writing
This history is used to
write admission orders
This history is compared to
admission orders and any
discrepancies are reconciled
PREVENTS ERRORS
CATCHES ERRORS
Nurse/Physician/Pharmacy performs medication history at time of
admission and prior to admission orders being written
Medication History & Orders Form used to document
medication history
Medication history documented in traditional locations in the
patient’s chart
Physician uses Medication History & Orders Form to indicate
continuation, discontinuation or change to pre-admission
medications. Any others admission orders are written on usual
physician order sheet
Physician uses usual physician order sheet to write admission
orders
Orders are processed to pharmacy using Medication History &
Orders Form for any pre-admit medications and using the
physician’s order sheet for new admission orders
Orders are processed to pharmacy using usual physician
order sheet
Pharmacy dispensary receives the orders and processes as usual
If a Medication History & Orders Form was completed in the admission order writing process, no further medication reconciliation
is required
All patient admitted without a completed Medication History & Orders Form will be assessed using the Assessment of Patient Risk
(APR) Tool to determine all high risk patients requiring the completion of a Medication Reconciliation process
Patients deemed high risk using the
Assessment of Patient Risk (APR) Tool will be referred
to the Clinical Pharmacy team
The Medication History & Orders Form will be used as
a worksheet to collect and document the medication
history.
(Additional patient may be audited if time permits)
Clinical Pharmacy team will compare admission orders to
medication history using the Medication History & Orders
Form as a worksheet to document any discrepancies.
If potential discrepancies are identified, a Discrepancy
Clarification & Resolution Form will be completed and will
be referred to the Clinical Pharmacist along with a copy of the
Medication History Worksheet
The Clinical Pharmacist will review potential discrepancies
and determine urgency to clarify.
If not urgent, the Discrepancy Clarification & Resolution
Form will be placed on the patient’s chart for completion by
the physician upon his/her next visit.
If urgent, the pharmacist will contact the physician by phone
to clarify and will write verbal orders onto the Discrepancy
Clarification & Resolution Form and will place in the
patient’s chart to be processed as an order.
The Clinical Pharmacy team will review patient charts daily and
will follow until all discrepancies are resolved.
Once physician clarifies discrepancies, Clinical Pharmacy team
will classify the outstanding discrepancies on the Medication
History Worksheet and will file.
All statistics will be compiled and reported in a monthly report.
• To reconcile patients within 24 hours of
admission
• At a minimum, target “high-risk” patients
identified using the
Assessment of Patient Risk (APR) Tool
Reconcile patients who have scored  10 or have
been admitted as a result of a drug-related problem
• If time permits, set a goal to reconcile as many
patients as possible, if not ALL
Assessment of Patient Risk (circle all applicable factors)
0 – 64 years
0
65 – 80 years
1
> 80 years
2
0-1
0
2-4
2
5-7
3
8 or more
6
Antiseizure
3
Anticoagulant
3
More than two cardiovascular medications
5
Diabetic medications (oral +/- insulin)
2
Age
Number of Medications Prior to Admission
High Risk Medications
Prior to Admission
Is the reason for admission clearly drug-related (e.g. drug toxicity, non-compliance, polypharmacy)?
Total Score
Yes
No
9
•
Antiseizure
• carbamazepine, phenytoin, valproic acid & divalproex sodium.
•
Anticoagulants
• warfarin, low molecular weight heparin (e.g. enoxaparin, nadroparin), heparin.
• NOT ASA.
•
Diabetic medications
• Chlorpropamide, gliclazide, glyburide, metformin, rosiglitazone
•
Cardiovascular Medications
• blood pressure meds, cholesterol meds, digoxin, amiodarone, daily ASA, clopidogrel,
diuretics.
• Do not count anticoagulants as a cardiovascular medication.
Assessment of Patient Risk (circle all applicable factors)
0 – 64 years
0
65 – 80 years
1
> 80 years
2
0-1
0
2-4
2
5-7
3
8 or more
6
Antiseizure
3
Anticoagulant
3
More than two cardiovascular medications
5
Diabetic medications (oral +/- insulin)
2
Age
Number of Medications Prior to Admission
High Risk Medications
Prior to Admission
Is the reason for admission clearly drug-related (e.g. drug toxicity, non-compliance, polypharmacy)?
Total Score
Yes
No
0
Assessment of Patient Risk (circle all applicable factors)
0 – 64 years
0
65 – 80 years
1
> 80 years
2
0-1
0
2-4
2
5-7
3
8 or more
6
Antiseizure
3
Anticoagulant
3
More than two cardiovascular medications
5
Diabetic medications (oral +/- insulin)
2
Age
Number of Medications Prior to Admission
High Risk Medications
Prior to Admission
Is the reason for admission clearly drug-related (e.g. drug toxicity, non-compliance, polypharmacy)?
Total Score
Yes
No
10
Referral to Clinical Pharmacy Team Recommended/Required?
 Yes
 No
 Unsure
Reason for referral:
Example #1: Patient experiencing digoxin toxicity
Form completed by: Alana Froese
Date: Today’s Date
Example #2: Scored 12
If total score is  10, if referral to a
pharmacist is recommended or if the reason
for admission is drug-related - place form in
troubleshooting file
Case Study: Carol Harrison
• Admitted to Emergency Department at
0800hr with palpitations, tremor and flushing
• Apparently patient thought her theophylline
was acetaminophen extra strength and took
two tablets at approximately 0400hr
• Review her Pharmanet record and determine
if she is considered “high risk” and a
candidate for Medication Reconciliation
MEDICATION RECONCILIATION
Patient Name:
Carol Harrison
ASSESSMENT of PATIENT RISK (APR) TOOL
Assessment of Patient Risk (circle all applicable factors)
0 – 64 years
Age
65 – 80 years
> 80 years
0-1
Number of Medications
2-4
Prior to Admission
5-7
8 or more
Antiseizure
Anticoagulant
High Risk Medications
More than two cardiovascular
Prior to Admission
medications
Diabetic medications (oral +/insulin)
Is the reason for admission clearly drug-related (e.g. drug
toxicity, non-compliance, polypharmacy)?
0
1
2
0
2
3
6
3
3
5
Examples of medications for each
medication category:
Antiseizure e.g. carbamazepine,
phenytoin, valproic acid &
divalproex sodium.
Anticoagulants e.g. warfarin, low
molecular weight heparin (e.g.
enoxaparin, nadroparin), heparin.
NOT ASA.
Cardiovascular Medications
e.g. blood pressure meds,
Yes cholesterol meds, digoxin,
No amiodarone, daily ASA,
clopidogrel, diuretics.
Total Score
Do not count anticoagulants as a
cardiovascular medication.
Referral to Pharmacist Recommended/Required?
 Yes
 No  Unsure
2
Reason for referral:
Admitted for drug-related problem – excess use of theophylline
Form completed by:
Date:
Alana Froese
Today’s Date
If total score is  10, if referral to a
pharmacist is recommended or if the
reason for admission is drug-related place form in troubleshooting file
Definition
A medication history obtained by a
healthcare professional which includes a
thorough history of all regular medication
use (prescription and non-prescription)
•
•
•
•
•
•
•
•
Patient – best source if patient competent
Caregiver
Pharmanet
Prescription vials/Compliance packaging
Medication List
Pharmacy
Family Physician
MAR from previous institution
• Print Pharmanet record
• Addressograph Forms
• Determine if patient is capable of
providing med history
• Pharmanet is simply a record of the
DISPENSING HISTORY
– Does not indicate the medications discontinued or
active or if the patient is taking the medications as
prescribed
– Does not include HIV/AIDS medications
– Does not include samples given to patients in
doctor offices
– Does not include physician office changes (without
writing a prescription)
– Does not include medications given in hospitals
• Medinet is a provider of Pharmanet info
For Demo Purposes
Pharmanet medication information for past 15 months
9029 820 762 HARRISON, CAROL A – 1927 Feb 01 – F
Demographics
Reported Clinical Conditions – 1 found:
PHN – Personal Health
Number (Care Card #)
HYPERCHOLESTEREMIA
1999 Mar 01
Patient
Name
Reported Adverse Reactions – 2 found:
510645
2000 Jul 18
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
P1/02301
RASH
2043246
1996 Jan 01
PENICILLIN G POTASSIUM WYETH-AYERST CA 10MU VIAL
91/15399
ANAPHYLAXIS
Reported Medication History – 15 of 15 printed:
510645
14 @ 2/day
Reversed:
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
TAKE ONE TABLET TWICE DAILY
2006 May 30
91/07692 (HARDY) Prescription cancelled by physician
2169126
250 @ 8.333/day
Filled:
P-EPHED HCL/CODEINE/TRIPROL RATIOPHARM 30-10-2/5 LIQUID
TAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED
2006 Mar 29
91/03361 (LAVOY)
28053
15 @ 2.143/day
Filled:
SULFACETAMIDE SODIUM SCHERING CANADA 10% DROPS
2 DROPS IN EACH EYE EVERY 3 HOURS FOR 7 DAYS
2006 Mar 24
91/03361 (LAVOY)
2213672
120 @ 4/day
FLUTICASONE PROPIONATE GLAXO SMITH KLINE 50MCG SPRAY
USE TWO SPRAYS IN EACH NOSTRIL DAILY
Date of Birth
Sex
For Demo Purposes
Pharmanet medication information for past 15 months
9029 820 762 HARRISON, CAROL A – 1927 Feb 01 – F
Reported Clinical Conditions – 1 found:
HYPERCHOLESTEREMIA
1999 Mar 01
Patient
Reported Adverse Reactions – 2 found:
510645
2000 Jul 18
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
P1/02301
RASH
2043246
1996 Jan 01
PENICILLIN G POTASSIUM WYETH-AYERST CA 10MU VIAL
91/15399
ANAPHYLAXIS
Reported Medication History – 15 of 15 printed:
510645
14 @ 2/day
Reversed:
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
TAKE ONE TABLET TWICE DAILY
2006 May 30
91/07692 (HARDY) Prescription cancelled by physician
2169126
250 @ 8.333/day
Filled:
P-EPHED HCL/CODEINE/TRIPROL RATIOPHARM 30-10-2/5 LIQUID
TAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED
2006 Mar 29
91/03361 (LAVOY)
28053
15 @ 2.143/day
Filled:
SULFACETAMIDE SODIUM SCHERING CANADA 10% DROPS
2 DROPS IN EACH EYE EVERY 3 HOURS FOR 7 DAYS
2006 Mar 24
91/03361 (LAVOY)
2213672
120 @ 4/day
FLUTICASONE PROPIONATE GLAXO SMITH KLINE 50MCG SPRAY
USE TWO SPRAYS IN EACH NOSTRIL DAILY
Clinical conditions
Typically this area is not
used
Reported by
Date reported
For Demo Purposes
Pharmanet medication information for past 15 months
9029 820 762 HARRISON, CAROL A – 1927 Feb 01 – F
Reported Clinical Conditions – 1 found:
HYPERCHOLESTEREMIA
1999 Mar 01
Patient
Reported Adverse Reactions – 2 found:
510645
2000 Jul 18
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
P1/02301
RASH
2043246
1996 Jan 01
PENICILLIN G POTASSIUM WYETH-AYERST CA 10MU VIAL
91/15399
ANAPHYLAXIS
Allergies and Reactions
Can not guarantee this is an
accurate listing of allergies
Reported by:
Date reported
PRACTITIONER CODES
Reported Medication History – 15 of 15 printed:
510645
14 @ 2/day
Reversed:
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
TAKE ONE TABLET TWICE DAILY
2006 May 30
91/07692 (HARDY) Prescription cancelled by physician
V9
Veterinarian
91
Physician/Surgeo
n
2169126
250 @ 8.333/day
Filled:
P-EPHED HCL/CODEINE/TRIPROL RATIOPHARM 30-10-2/5 LIQUID
TAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED
2006 Mar 29
91/03361 (LAVOY)
28053
15 @ 2.143/day
Filled:
SULFACETAMIDE SODIUM SCHERING CANADA 10% DROPS
2 DROPS IN EACH EYE EVERY 3 HOURS FOR 7 DAYS
2006 Mar 24
91/03361 (LAVOY)
2213672
120 @ 4/day
FLUTICASONE PROPIONATE GLAXO SMITH KLINE 50MCG SPRAY
USE TWO SPRAYS IN EACH NOSTRIL DAILY
95
Dentist
P1
Pharmacist
93
Podiatrist
98
Midwife
For Demo Purposes
Pharmanet medication information for past 15 months
9029 820 762 HARRISON, CAROL A – 1927 Feb 01 – F
Reported Clinical Conditions – 1 found:
HYPERCHOLESTEREMIA
1999 Mar 01
Patient
Reported Adverse Reactions – 2 found:
510645
2000 Jul 18
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
P1/02301
RASH
2043246
1996 Jan 01
PENICILLIN G POTASSIUM WYETH-AYERST CA 10MU VIAL
91/15399
ANAPHYLAXIS
Reported Medication History – 15 of 15 printed:
510645
14 @ 2/day
Reversed:
SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET
TAKE ONE TABLET TWICE DAILY
2006 May 30
91/07692 (HARDY) Prescription cancelled by physician
Dispensing History
-Most recent reported first
-Drug by generic name(s)
-Drug Identification
Number (DIN)
-Quantity
2169126
250 @ 8.333/day
Filled:
P-EPHED HCL/CODEINE/TRIPROL RATIOPHARM 30-10-2/5 LIQUID
TAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED
2006 Mar 29
91/03361 (LAVOY)
-Sig (Instructions)
28053
15 @ 2.143/day
Filled:
SULFACETAMIDE SODIUM SCHERING CANADA 10% DROPS
2 DROPS IN EACH EYE EVERY 3 HOURS FOR 7 DAYS
2006 Mar 24
91/03361 (LAVOY)
-Date Filled or Reversed
2213672
120 @ 4/day
FLUTICASONE PROPIONATE GLAXO SMITH KLINE 50MCG SPRAY
USE TWO SPRAYS IN EACH NOSTRIL DAILY
-Physician
• Review entire dispensing history
• Multidoctoring? – scan for number of physicians
dispensing
• Non-compliance? – are chronic meds being
filled at regular intervals
• Consider how much of the history to print
– Look for intermittently used medications that may
still be considered active orders and ensure they are
included when printed
» Salbutamol MDI 2 puffs q4h prn
» Topical creams
• If you can not identify a drug by its generic name(s),
searching Canada’s Drug Product Database using the Drug
Identification Number (DIN) will help you identify the brand
name and manufacturer
– http://www.hc-sc.gc.ca/hpb/drugs-dpd/
2169126
250 @ 8.333/day
Filled:
P-EPHED HCL/CODEINE/TRIPROL RATIOPHARM 30-10-2/5 LIQUID
TAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED
2006 Mar 29
91/03361 (LAVOY)
Ratio – Cotridin
• What’s in the Drug name
– List of active chemical entities
• Generic name(s)
– Sometimes includes secondary name
• Example: Salts of Erythromycin base
• Estolate, Ethylsuccinate, Lactobionate
– Additional product information
• Strength & Formulation
– Listed between the name and strength of the product
• Manufacturer
21016
60 @ 1/day
Filled:
QUININE SULFATE NOVOPHARM LTD 300MG CAPSULE
TAKE ONE CAPSULE AT BEDTIME AS NEEDED FOR LEG CRAMPS
2005 Dec 04
91/02295 (MACKAY)
• Watch for specialty formulation information
2014165
90 @ 1/day
Filled:
THEOPHYLLINE ANHYDROUS PURDUE PHARMA 400MG TAB SR 24H
TAKE ONE TABLET ONCE DAILY
2006 Mar 04
91/02295 (MACKAY)
02202441
56 @ 2/day
Filled:
OXYCODONE PURDUE PHARMA 10MG TABLET CR
TAKE ONE TABLET EVERY 12 HOURS
2006 May 22 91/05568 (BROWN)
2007959
90 @ 1/day
Filled:
ACETYLSALICYLIC ACID PHARMASCIENCE 81MG TABLET DR
TAKE ONE TABLET ONCE DAILY
2006 Mar 04
91/02295 (MACKAY)
2237280
60 @ 1/day
Filled:
Sustained
Release
Controlled
Release
VENLAFAXINE WYETH CANADA 75MG CAPSULE XR
TAKE ONE CAPSULE ONCE DAILY
2006 Apr 15
91/05568 (BROWN)
Delayed
Release
Extended
Release
• Time commitment – Goal 15min
• Confirm positive identification of patient
• Introduce yourself and explain your role
– Tell patient you would like to ask him/her
some questions about his/her medication
use
– Ask if this is a good time
• If not, schedule another time
• Ask questions until
you are confident all
information is
complete and
reliable
– Pursue unclear
answers until they
are clarified
• Use open-ended
questions (what,
how, why, when)
balanced with yes/no
questions
WHAT medication do you take?
Ramipril
WHAT is the strength of the Ramipril?
10mg
HOW often do you take it?
Once daily
WHEN do you take your Ramipril each
day?
Lunch time
Do you ever forget to take your Ramipril?
No
• Use nonbiased
questions
– Do not lead
the patient
into answering
something
that may not
be true
WHAT NOT TO DO
So you are taking Ramipril?
Yes
…and your Ramipril is a 10mg capsule?
Yes
…and the Pharmanet record says you take it
once daily?
Yes
…and you take this with your other meds in
the morning?
Yes
…and you are taking routinely without
forgetting a dose?
Yes
• Ask simple
questions
– Avoid using
medical jargon
Are you taking any OTC meds?
Are you taking any non-prescription
medications?
Do you take your lorazepam orally or
sublingually?
Do you swallow your lorazepam whole or do
you place it under your tongue?
• Prompt the patient to remember all
medications
– Prescriptions
• Patches, creams, eye drops, inhalers, sample
medications
– Over-the-counter (OTC) medications
– Herbal and other natural remedies
– Vitamins and minerals
• Use “head-to-toe” Review of Systems
approach
• HEENT
–
–
–
–
–
–
Nose, ear or eye drops
Analgesics used for headache or sinus pain
Dental products
Insomnia
Motion sickness
Smoking Cessation aids
• Cardiovascular
– Once Daily ASA
• Respiratory tract
– Antihistamines
– Decongestants
• GI/GU
–
–
–
–
–
–
Antacids
Antiflatulants
Antidiarrheals
Laxatives
Hemorrhoidal preparations
Vaginal antiinfectives
• Musculoskeletal
– ASA
– Anti-inflammatory agents
– Acetaminophen or combination
• Dermatological
–
–
–
–
Psoriatic/Seborrheic
Antiinfective
Analgesic topical preparation
Corns/callus pads or other foot care
• Hematological
– Consider iron, B12, folic acid
• Overall/System-wide
– Vitamins
– Herbal
– Homeopathic or other alternative
healthcare products
• Indication
– This is the patient’s version of the indication
• Efficacy
– Tell me how you know this medication is working
for you?
• Toxicity
– Are there any problems that you are having which
you think may be caused by this medication?
– If patient says no, probe with a few of the most
common side effects
• Compliance
– How often do you take this medication?
– Try to verify if cost, dosing frequency, adverse effects, or
personal beliefs may be an obstacle
• How do you feel your medications impact your life?
• Tell me how you feel about medication use, in
general?
– Inquire about technique and maintenance of devices
used to facilitate drug delivery or monitor drug therapy
• Inhalers and Spacers, BP monitors, Blood glucose
monitors
Case Study: Carol Harrison
• Interview Carol and document the
medication history on the blank
Medication History sheet
• Use Carol’s Pharmanet record and
prescription vials to guide your
questions
Allergies/Intolerances
(specify reactions)
Penicillin – Hives
Peanuts – Anaphylaxis
Ibuprofen – GI upset
Eggs? - Rxn Unknown
•
•
•
 NKA
Weight
Height
______  kg  lbs
______  m / cm  ft / in
 Estimated  Actual
 Estimated  Actual
True Allergy
– Drug, food, additives, etc
– Immunologically mediated reaction
• Type I – Type IV (see Coombs & Gell Classification)
Possible Allergy
– Vague/incomplete history of allergic reaction
– Assume worst case scenario
– Include “?”
Intolerance
– Side effects or adverse events
– Predictable response
• N&V, GI upset
Allergies/Intolerances
(specify reactions)
Penicillin – Hives
Peanuts – Anaphylaxis
Ibuprofen – GI upset
Eggs? - Rxn Unknown
 NKA
Weight
__
76.8___  kg
Height
 lbs
 Estimated  Actual
______  m / cm  ft / in
 Estimated  Actual
• Medication dosing is frequently dependent on
weight
• Document patient’s weight in kilograms (kg) or
pound (lbs)
– Actual
• Hospital weigh scale
– Estimate
• Patient report
• Nursing estimation
Allergies/Intolerances
(specify reactions)
Penicillin – Hives
Peanuts – Anaphylaxis
Ibuprofen – GI upset
Eggs? - Rxn Unknown
 NKA
Weight
__
76.8___  kg
Height
 lbs
 Estimated  Actual
5’ 6’’_
_
 m / cm  ft / in
 Estimated  Actual
• Some medications require the patient’s
height as well
• Document patient’s height in either
m/cm or ft/in
• Only use actual if patient’s height is
measured by a healthcare professional
at the time of admission
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate
CHANGE ORDER
COMMENTS
Last Dose Date/Time
D/C
CONTINUE
• MEDICATION NAME
– Document generic name - chemical name of drug
• If two chemical ingredients, list both
– Avoid use of brand names
• Exception: multi-ingredient drugs
– Sofracort – framycetin/gramicidin/dexamethasone
– Include full name (Erythromycin base, Erythromycin estolate)
– Avoid use of abbreviations
• Exception: ASA - Acetylsalicylic acid
CHANGE
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate
suspension
CHANGE ORDER
COMMENTS
Last Dose Date/Time
• FORMULATION
– Acceptable to use abbreviations
• Dosage forms
– Susp or Liq - suspension or liquid
– Tab or Cap – tablet or capsule
• Special formulations
– EC – enteric coated
– SR – sustained release
D/C
CONTINUE
CHANGE
Generic Name
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate
suspension
Dose
Route
Floor
Use
Frequency
500mg/
125mg(5ml)
CHANGE ORDER
COMMENTS
•
Last Dose Date/Time
DOSE
– Weight
• mg = milligram, g = gram, mcg = microgram
– Do not use µg – confused with mg
– Volume
• ml = millilitres, L = litres
– Miscellaneous
• units
– Do not use U or u – confused as zero
• International Units
– Do not use IU – confused with IV or 10 (ten)
D/C
CONTINUE
CHANGE
Generic Name
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate
suspension
Dose
500mg/
125mg(5ml)
Route
Floor
Use
Frequency
PO
CHANGE ORDER
COMMENTS
Last Dose Date/Time
• Route
–
–
–
–
–
po – oral
ng – nasogastric
sc – subcutaneous
im – intramuscular
iv – intravenous
D/C
CONTINUE
CHANGE
Generic Name
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate
suspension
Dose
500mg/
125mg(5ml)
Route
PO
Floor
Use
Frequency
TID
CHANGE ORDER
COMMENTS
Last Dose Date/Time
• FREQUENCY
– daily
• Do not use q.d. or QD
– q2days
• Do not use q.o.d. or QOD
– BID, TID, QID
– q4h, q6h, q8h
– 5 times daily
D/C
CONTINUE
CHANGE
Generic Name
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate
suspension
Dose
500mg/
125mg(5ml)
Route
PO
Floor
Use
Frequency
TID
CHANGE ORDER
COMMENTS
2 days of 7 days completed
Last Dose Date/Time
D/C
CONTINUE
CHANGE
• Duration
– If patient has been on medication < 3 months, use
comment section to document this information
• wks, mths, days, doses…
– If medication ordered for specific duration
• Indicate time taken in relation to prescribed duration in
comment section
– 2 doses of 14 days
Generic Name
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate
suspension
Dose
500mg/
125mg(5ml)
Route
PO
Floor
Use
Frequency
TID
CHANGE ORDER
COMMENTS
Last Dose Date/Time
D/C
CONTINUE
CHANGE
Acute Sinusitis
Non-compliance: taking bid
2 days of 7 days completed
• Comments
– Indication as reported by patient if known
– Adverse events experienced?
– Physician directed patient to reduce dose
at last office visit
– Non-compliance
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Ranitidine 75mg tablets
(Zantac)
150mg
PO
DAILY PRN
CHANGE ORDER
COMMENTS
used occasionally to treat heartburn
6 episodes/mth
Last Dose Date/Time
Not taken
in past
week
D/C
CONTINUE
CHANGE
• Last dose (date/time)
– Documentation not necessary if patient is already receiving
treatment in hospital
– Helpful in cases where patient uses a medication prn and has not
used the medication in the past week
– Use 24hr hospital time
– Month and day is adequate
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Ibuprofen
400mg
PO
TID PRN
CHANGE ORDER
COMMENTS
Headaches 1-2 episodes/month
Last Dose Date/Time
1200hr
Sep 12
D/C
CONTINUE
CHANGE
SPECIAL SITUATIONS
• Documenting PRN’s
– Record frequency if there is a pattern
– Include indication and frequency of episodes
– Record in “Last Dose” column if medication not
taken in past week
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Etidronate 400mg/Calcium
1250mg Kit
1 tab
PO
Daily
CHANGE ORDER
COMMENTS
Osteoporosis
56 tablets left in 90 day kit
Last Dose Date/Time
0800hr
Sep 12
D/C
CONTINUE
CHANGE
SPECIAL SITUATIONS
• Medications given in cycles
– Didrocal kit – note where patient is in 90 day cycle
Generic Name
PRE-ADMISSION MEDICATION
Cyanocobalamin
Dose
1,000 mcg
(1ml)
Route
IM
Floor
Use
Frequency
Monthly
CHANGE ORDER
COMMENTS
Anemia
Next dose due: Oct 21
Last Dose Date/Time
0800hr
Sep 21
D/C
CONTINUE
CHANGE
• SPECIAL SITUATION
– Medications given at intervals
• Note due date of next dose as well as last dose
Source of Information
Verification Codes
 Interviewed Patient
 Poor Historian
 Pharmanet
 Prescription containers
 Caregiver _
Jane Smith_ Ph: 987-4321
 Medication List
Wal-Mart _
 MAR
 Pharmacy _
Ph: 987-6543
1 Indication
5 Wrong Drug
2 No Indication
6 Non-Compliance
3 Dose Too Low
7 Adverse Event
4 Dose Too High
8 Drug Interaction
 Other________________
History Documented by
Date/Time
• Indicate Source of Information
– Ideal to interview patient
• Limitations if patient:
– Confused
– Does not speak English
– Too ill to interview
– A good idea to document Pharmacy and Caregiver contact
info in the event more information is needed later
Source of Information
Verification Codes
 Interviewed Patient
 Poor Historian
 Pharmanet
 Prescription containers
 Caregiver _
Jane Smith_ Ph: 987-4321
 Medication List
Wal-Mart _
 MAR
 Pharmacy _
Ph: 987-6543
 Other________________
History Documented by
Alana Froese
Date/Time
Today’s Date
• Sign your name
• Record date and time
1 Indication
5 Wrong Drug
2 No Indication
6 Non-Compliance
3 Dose Too Low
7 Adverse Event
4 Dose Too High
8 Drug Interaction
Case Study: Evelyn Smith
• Use the new Medication History
worksheet to interview Evelyn Smith
• Evelyn was admitted to Emergency with
mild confusion and dehydration
• She has not brought in her prescription
vials however, you have printed her
Pharmanet record in preparation for the
interview
• Access the patient’s chart to compare
admission orders to the medication
history documented
• Look in history or progress note sections
of patient chart for reason for any
changes
• You are going to be shown how you can
use this information to identify and
document discrepancies
• Type 0 - No Discrepancy
• Type 1 - Intentional
• Physician has made an intentional choice to add,
change, discontinue a medication
• Choice is clearly documented
• Type 2 - Undocumented Intentional
• Physician has made an intentional choice to add,
change, discontinue a medication
• Choice is not clearly documented
• Type 3 - Unintentional
• Physician unintentionally changed, added, or omitted a
medication the patient was taking prior to admission
• Purpose
– A quick method used to indicate physician’s
reason for continuing, changing or
discontinuing a pre-admission medication
Verification Codes
1 Indication
5 Wrong Drug
2 No Indication
6 Non-Compliance
3 Dose Too Low
7 Adverse Event
4 Dose Too High
8 Drug Interaction
• INDICATION
 Patient has a diagnosed problem which requires a
drug therapy
 New symptoms or indication revealed/presented
 Preventative drug required
 Taking a drug for valid indication, but this drug causes
side effects which require prophylactic therapy
 Synergistic drug required
 Requires synergistic drug therapy to potentiate effect of
current drug therapy
• NO INDICATION
No clear indication for drug use
Improvement of disease state
Receiving drug chronically which was intended
for acute condition
Recreational use, addiction/dependence
Condition can be more appropriately treated by
non-drug therapy
Receiving a drug to treat an avoidable ADR
Inappropriate duplication of therapeutic
class or active ingredient
• DOSE TOO LOW/DURATION TOO SHORT
Drug dose too low (sub-therapeutic)
Dosage regime not frequent enough
Duration of treatment too short
• DOSE TOO HIGH/DURATION TOO
LONG
Drug dose too high (dose dependent
toxicity)
Dosage regime too frequent
Duration of treatment too long
• WRONG DRUG
 Inappropriate drug
 Inappropriate drug or dosage selection
 More cost effective drug available
 Drug therapy is known to be ineffective for this indication
 Drug therapy is effective for this indication, but not effective
in this patient for unknown reasons
 Inappropriate drug form
 Cannot take the drug product (swallow, taste, administration)
 Contraindication for drug (incl. pregnancy/
breastfeeding)
• NON-COMPLIANCE
 Patient is not compliant
 Drug underused, overused or abused
 Patient has difficulties reading/understanding
 Drug not taken/administered at all
 Patient unable to use drug/form as directed
 Patient unwilling to carry financial costs
 Prescribed drug not available
 Wrong drug taken/administered
 Prescribing error
 Dispensing error (wrong drug or dose dispensed)
 Administration error (by patient/caregivers)
• ADVERSE EVENT
Side effect suffered at a therapeutic dose
(non-allergic)
Side effect suffered at a therapeutic dose
(allergic)
Toxic effects suffered
• DRUG INTERACTION
Potential or actual Drug/Drug interaction
Potential or actual Drug/Food interaction
Potential or actual Drug/Laboratory
interaction
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO
BID
CHANGE ORDER
0
COMMENTS
Last Dose Date/Time
D/C
CONTINUE
CHANGE
1
• If there is no change, add the
verification code “1” to the continue box
• Document a Type 0 discrepancy in the
“Floor Use” section
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO
BID
5mg
PO
Daily
CHANGE ORDER
Ramipril
COMMENTS
Last Dose Date/Time
D/C
1
CONTINUE
CHANGE
4
• When there are differences, write the admission order
below the medication in question
• If a reason for the change has been documented by
the ordering physician, use one of the verification
codes to indicate the intention of the change
• Document a Type 1 discrepancy in the “Floor Use”
section
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Hydrochlorothiazide
25mg
PO
QAM
12.5mg
PO
QAM
CHANGE ORDER
Hydrochlorothiazide
COMMENTS
Last Dose Date/Time
D/C
?
CONTINUE
CHANGE
?
• If a reason for the change has NOT been documented
by the ordering physician, this discrepancy may either
be a Type 2 or Type 3 discrepancy
• Clarification with the ordering physician will be
required before the type of the discrepancy can be
documented
• In this case, leave “undocumented” until resolved by
the clinical pharmacist
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO
BID
CHANGE ORDER
Nil
COMMENTS
1
Last Dose Date/Time
D/C
CONTINUE
CHANGE
7
• When there are no matching admission orders, write
“nil” below the medication in question
• If a reason for the discontinuation has been
documented by the ordering physician, use one of the
verification codes to indicate the intention to stop
• Document a Type 1 discrepancy in the “Floor Use”
section
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO
BID
CHANGE ORDER
Nil
COMMENTS
?
Last Dose Date/Time
D/C
CONTINUE
CHANGE
?
• If a reason for the discontinuation has NOT been
documented by the ordering physician, this discrepancy
may either be a Type 2 or Type 3 discrepancy
• Clarification with the ordering physician will be required
before the type of the discrepancy can be documented
• In this case, leave “undocumented” until resolved by
the clinical pharmacist
Case Study: Evelyn Smith
• You have been to Evelyn’s chart and have
reviewed the admission orders
– See physician order sheet provided to you
• The only place in the chart you could find
explanations for changes to pre-admission
medications is on the actual physician order
sheet.
• Begin the reconciliation process by comparing
the medication history to the admission
medications ordered and filling out the
second part of the Medication History form
• All potential type 2 or 3 discrepancies are
to be documented on the Discrepancy
Clarification & Resolution Form
• Addressograph the form
• Transcribe all information collected on potential
type 2 or 3 discrepancies onto this second form
• Document sources of information
• Include signature and date under source of
information section
• Direct both forms to the Clinical Pharmacist for
review and clarification/resolution
• After reviewing and assessing level of
urgency to resolve, the pharmacist may
choose to either:
• Place the form on the patient’s chart to be completed by
the physician OR
• Calling the physician for clarification and writing verbal
orders onto the form then placing the form onto the
patient’s chart for processing OR
• Using the form as a worksheet only and, after clarifying,
writing the verbal orders into the patient’s chart
Generic Name
Dose
Route
Frequency
PRE-ADMISSION MEDICATION
Hydrochlorothiazide
25mg
PO
QAM
12.5mg
PO
QAM
ORDER AT ADMISSION
Hydrochlorothiazide
COMMENTS
Hypertension
 Continue admission
order
 Revert to pre-admission
order
• If the physician states he/she intended
to change the order but did not
document this on the patient’s chart, the
physician/pharmacist will indicate
“Continue Admission Order”
Floor
Use
Generic Name
Dose
Route
Frequency
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO
BID
ORDER AT ADMISSION
Nil
COMMENTS
Hypertension
 Continue admission
order
 Revert to pre-admission
order
• If the physician states he/she DID NOT
intend to change the order, the
physician/pharmacist will indicate
“Revert to Pre-Admission Order”
Floor
Use
Source of Information
Discrepancy Types
Undocumented Intentional
 Resolution: Continue
admission order
 Interviewed Patient
 Caregiver _
 Poor Historian
Jane Smith_ Ph: 987-4321
 Pharmacy _
Wal-Mart _
History Documented by
 Pharmanet
 Prescription containers
 Medication List
 MAR
 Other________________
Unintentional
 Resolution: Revert to preadmission order
Ph: 987-6543
Nancy Green
Date/Time
Today’s Date
 Faxed to Pharmacy
Authorizing Physician
v/o Dr. B. Brown/Alana Froese
Date/Time Today’s Date
Pages ____ of ____
• Physician/Pharmacist to sign and date at bottom of
form
• Ideally, to be placed in patient’s chart and processed as
an order
Case Study: Evelyn Smith
• Complete a Discrepancy Clarification & Resolution
form
– Ensure all potential type 2 & 3 discrepancies are filled
in on the form
– Refer this form as well as your original Medication
History to your pharmacist for review
– In this case, the pharmacist determined the physician
should be called to clarify discrepancies
– Call physician and document clarifications on
Discrepancy Clarification & Resolution form
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Hydrochlorothiazide
25mg
PO
QAM
12.5mg
PO
QAM
CHANGE ORDER
Hydrochlorothiazide
COMMENTS
Last Dose Date/Time
D/C
2
CONTINUE
CHANGE
4
• BACK TO THE MEDICATION HISTORY WORKSHEET…
• A member of the Clinical Pharmacy team will
indicate the reason for an undocumented
intended change once clarified
• Place a verification code in the change box
• In this case, a Type 2 discrepancy is documented in the Floor
Use box
Generic Name
Dose
Route
Floor
Use
Frequency
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO
BID
CHANGE ORDER
Nil
COMMENTS
3
Last Dose Date/Time
D/C
CONTINUE
CHANGE
1
• If an Unintentional Discrepancy is identified
• Indicate a Type 3 discrepancy in the Floor Use box
• In this situation, the physician reverted to the preadmission order indicating a true error occurred
 Faxed to Pharmacy
Authorizing Physician
Dr. B. Brown/Alana Froese
Date/Time Today’s Date
Pages __1__ of __1__
• The person who completes the resolution
information must indicate the physician who
was involved and sign/date the bottom of the
form
• As this is considered a worksheet only, the
Faxed to Pharmacy section is not used and
this form is not processed as an order
• The Pharmacy Technician will be responsible
for maintaining all forms, compiling statistics
and generating monthly discrepancy reports
Case Study: Evelyn Smith
– The final step!
– Document resolutions on Medication History
form
– Return to Technician to compile statistics
Generic Name
Dose
Route
Frequency
Floor
Use
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO
BID
UC
ORDER AT ADMISSION
Nil
RN
COMMENTS
Hypertension
 Continue admission
order
 Revert to pre-admission
order
• Unit Clerk/Nurse will transcribe orders to
MAR and initial in Floor Use section
• RN will check orders and accuracy of
transcription and will initial below the
first initials in the Floor Use section
Source of Information
Discrepancy Types
Undocumented Intentional
 Resolution: Continue
admission order
 Interviewed Patient
 Caregiver _
 Poor Historian
Jane Smith_ Ph: 987-4321
 Pharmacy _
Wal-Mart _
History Documented by
 Pharmanet
 Prescription containers
 Medication List
 MAR
 Other________________
Unintentional
 Resolution: Revert to preadmission order
Ph: 987-6543
Nancy Green
Date/Time
Today’s Date
 Faxed to Pharmacy
Authorizing Physician
v/o Dr. B. Brown/Alana Froese
Date/Time Today’s Date
1
1
Pages __ ___ of __ ___
• Unit Clerk/Nurse will indicate number of pages
& check Faxed to Pharmacy Box when sending
to pharmacy
Case Study: Carol Harrison
•
You have just completed a BPMH
1.
Compare the Physician Orders to the Medication History
1.
2.
3.
4.
5.
Note: you are unable to glean additional information
regarding the rational to therapeutic changes from other
sections in the chart
Document Discrepancies on Medication History form
Complete Discrepancy Clarification & Resolution (DCR)
form
Call physician to clarify discrepancies and document on
DCR form
Document resolution of discrepancies on Medication
History form
An accurate medication
history is performed prior
to physician admission
order writing
This history is used to
write admission orders
PREVENTS ERRORS
Nurse/Physician/Pharmacy use
Medication History & Orders Form to document
medication history
Physician uses Medication History & Orders
Form to indicate continuation, discontinuation or
change to pre-admission medications. Any others
admission orders are written on usual physician
order sheet
Orders are processed to pharmacy using
Medication History & Orders Form for any preadmit medications and using the physician’s
order sheet for any new admission orders
“The names of the patients whose lives we save can never be
known. Our contribution will be what did not happen to
them. And, though they are unknown, we will know
that mothers and fathers are at graduations and
weddings they would have missed, and that
grandchildren will know grandparents they might never
have known, and holidays will be taken, and work
completed, and books read, and symphonies heard, and
gardens tended that, without our work, would never have
been.”
Donald M. Berwick, MD, MPP
President and CEO
Institute for Healthcare Improvement