Download Medication Reconciliation PAC Education Poster August 12 2008

The Implementation of Medication Reconciliation in PAC Enhancing Patient Safety
Safer Health Care Now !
Implementing a Medication History/Admission Order Form
Medication Reconciliation?
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Medication History / Admission Order Form
Western Regional Integrated Health Authority
A process in which medications are compared at
interfaces of care:
Admission
Transfer
Discharge
Discrepancies are identified and reconciled with physician
Intervention minimizes patient harm from unintended
discrepancies
ISMP Canada 2005
MEDICATION HISTORY
ADMISSION MEDICATION ORDERS
gical InpatientsWMH
________(Indicate Site) Preadmission Clinic
**Keep this form with the Physician Orders**
Patient Label/Addressograph
This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for preadmission medications. New medication prescribed on admission should be written on the physician’s order sheet.
Source of Medication Information (Check ALL that apply)
 Review of patient/resident medication list
 Review of medication vials
 Review previous hospital records
 Family Physician list
 Patient/resident recall
 Family/caregiver recall
 MAR from another facility
 Other:__________________
 Community pharmacy list Pharmacy Name:______________________
Weight:
Height:
kg
cm
□
□
□
□
□
PAC Nurses: When the BPMH is
collected sign indicating so.
PAC Nurses: After collecting BPMH
list indicate Risk Score after
completing Risk Tool on back of
this form (Tool shown here)
Hold
Change
Continue
Discontinue
Verified/In
itial
Has the BPMH collected in PAC Changed? Yes  (Make Changes)No 
Prescribing Physician:
Date/Time:
BPMH obtained by:
________ Date/Time: __________
BPMH obtained by:
_________ Date/Time: __________
Additional Medications Identified After Medication History Taken
( Please Fax Additions to Pharmacy)
BPMH obtained by:
BPMH obtained by:
________ Date/Time: __________
________ Date/Time: __________
NOTE: For all additional preadmission medications received after the BPMH has
been completed still indicate intent regarding Continue, Discontinue, Change, Hold.
Physician: signs here for
approval of the boxes that
were checked with each
medication
Pre op Nurse: verifies that
nothing has changed since
medication list taken in
PAC. If Yes, note in
additional medication
section.
Please complete additional forms if additional space for medication list is needed.
Risk Score:
(see tool form #
) Pharmacy Consult Recommended
Reason for Referral:
NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not.
Disposition of Patient’s Medication on Admission:
 Locked up in nursing unit  Brought to hospital. Sent home with:
Original Copy – On Chart
Copy – to Pharmacy
 Not brought to hospital
Fax to Pharmacy: Pages(s)
of
.
 No
Form #
Patient Medication Risk Assessment Tool (circle all applicable factors)
High Risk Medications
Prior to Admission
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)
Is the patient confused regarding his/her medication regime?
Has the patient been hospitalized for medication management
concern within the last year?
Note: PAC Nurses do not fax this form to pharmacy on
the day the medication history and risk score is
completed in PAC Clinic. This is done post-op by
inpatient RN who is receiving the patient.
If Inpatient RN is in situation of receiving orders
by phone the RN checks the appropriate boxes as
ordered and signs here as per telephone / verbal
order. Later, to be cosigned by physician as per
usual policy.
Staff member verifying the medication for the
BPMH initials appropriate box for each
medication verified.
Examples of medications for each
medication category:
Antiseizure: e.g. carbamazepine,
phenytoin, valproic acid &
divalproex sodium.
Anticoagulants: e.g. warafin, low
molecular weight heparin (e.g.
tinzaparin, dalteparin, enoxaparin),
heparin. Not ASA.
Cardiovascular Medications:
e.g. blood pressure meds, cholesterol
meds, digoxin, amiodarone, daily
ASA, clopidogrel, diuretics.
Do not count anticoagulants as a
cardiovascular medication.
2
Automatic
Referral to
Pharmacy
Automatic
Referral to
Pharmacy
BPMH means obtaining the best possible medication list possible. Ensure you practice good
medication history taking techniques. Refer to Tips For Medication History Taking indicated below.
Ensure you consider all possible resources (as indicated on Medication History / Admission Order
Form) for information that can verify a current accurate medication list.
Tips For Medication History Taking
Inpatient RN: Following completion of orders the front and back
of this form (medication history/orders and completed Risk
Tool) is faxed to Pharmacy.
Questions to Ask for a Medication
History
Tips for Performing a Medication
History
1. Ask about all medications:
∙ Prescription
∙ Over-the-counter (non-prescription)
∙ Anything from a herbalist or health
food store
∙ Vitamins or supplements
∙ Traditional remedies
∙ Balance open-ended questions with yes
/ no questions
∙ Ask nonbiased questions
∙ Don’t ask leading questions
∙ Vague responses may indicate nonadherence
∙ Avoid medical jargon
∙ Encourage questions from patient
∙ Educate patient to bring medications
from home
∙ Educate resident to carry a list of
current medications
∙ Prompt regarding non-pill dosage forms
such as patches, creams, eye drops,
inhalers, sprays, samples, shots
∙ Do not assume instructions on
prescription vial labels are current. If the
medication vials are available, review
each medication individually with the
patient. Ask them how they take each
medication.
∙ Ensure the vial contains the medication
specified on the label.
∙ Prompt regarding prn medication
∙ Allergies: ask about symptoms
∙ Use multiple sources of information:
- Medication lists / vials
- Family
- Community Pharmacy
- Family physician
2. Include:
∙ Name
∙ Dosage form
∙ Dose
∙ Schedule
∙ Last dose taken
Note: be specific about prn
medication
3. Ask about recently started
medications or dosage
changes
Pharmacy: If Risk Score indicates, Pharmacy will also assess
patients BPMH and indicate any additions or revisions in the
Additional Medication section that is related to accuracy of the
BPMH. As well, will follow up by communicating to unit nursing
staff and / or physician of any recommendations related to the
medication regime. The referral process may take up to 48-72 hrs
for pharmacy to complete the patient assessment.
Other Questions for Medication History Interviews
Total Score
If total score is > or = to 10,
referral to Pharmacist is
recommended.
NOTE: Fax to Pharmacy on day of admission.
Such medications are listed in the Additional Medication section so that all pre-admission
medications are listed in one area. In addition, the physicians intention to continue, discontinue,
hold, change etc. should still be checked in the appropriate adjacent boxes by the nurse after
discussion with the physician. However, the physician order for these additional pre-admission
medications that are now noted at a later date is to be indicated on the pink Physician Order
sheet. This is because usual processes do not trigger a nurse to backtrack and check for orders
that may have been documented on a form initiated days before.
 Yes
Medication History / Admission Order Form
Age
3. Sometimes patients after initial day of admission report they take additional medications
that they forgot to indicate at the time the medication history was collected. Where are
these medications then listed and ordered?
4. How can I be sure I have a BPMH?
Note: Any additions to
Preadmission medication list/s
received after list above is verified
Requires the physician orders
written on routine Physician
Orders (pink form).
Number of Medications
Prior to Admission
Note: This completed form becomes the admission
medication history list. Therefore, to reduce duplication
and reduce potential for error with multiple lists any
other areas where medication history list have been
usually written (ie. admission history or nursing kardex)
should indicate for pre-admission medications “See
Medication History / Admission Orders List”
List all prescribed, OTC and herbal medications determined to be taken by the patient or
physician recommended medications? Once listed the ordering physician decides if the
medications listed then should be continued, discontinued, etc upon admission.
Reason for Change/Hold/Discontinuation
Physician: post-op checks appropriate boxes indicating if
pre-admission medications are for Continue, Change, Hold
or Discontinue. Also, indicate reason for Hold, Change or
Discontinue. Note: New medications that may be ordered
post op are indicated as usual on the pink Physician Order
Sheet.
PAC Nurses: If BPMH collected
by more than one RN indicate
both signatures.
Pre-op Nurses or Inpatient Nurses: If
additional regular pre admission /
transfer medications are identified after
initial BPMH was collected (ie. upon day
of admission for surgery or later)
indicate here and sign as addition to
BPMH.
2. Are all medications – OTC, herbal- listed when collecting the Best Possible Medication
(BPMH)?
PAC Nurses: Indicate any
illnesses patient has.
Physician Admission Orders:
To complete upon admission
Dosing
Interval
Dose
(List all prescriptions and regularly
taken OTC & PRN medications prior
to admission).
Determining the BPMH requires one to tap into all resources – patient / family interview,
community / hospital pharmacy, patient list or vials of medications upon initial admission, lists
noted in previous hospital chart. Note: the potential for adverse drug events occurs when we
assume the list accompanying the patient is verified for accuracy. Consider any red flags that
indicate patient may be prescribed or not prescribed a medication in error. Thoroughly investigate
as far as considered necessary to clarify accuracy of current medication list accompanying patient.
Remember this step is the most vital in preventing medication errors.
□ PVD □ Renal □ R.Arthritis □ Epilepsy
□ CVA
Failure □ O.Arthritis □ Anxiety
□ HTN □ COPD □ NIDDM
□ Depression
□ Multiple Sclerosis
□ IDDM
IHD
AFiB
CHF
Dyslipidemia
Other:
Allergies:
Route
Medication Name & Strength
1. How in depth do we become involved to clarify accuracy of medication list when
patients are unsure of complete medication list taking?
PAC Nurses: Ensure all sources
required to verify the Best Possible
Medication History (BPMH) are
indicated upon admission.
Diagnosis: (check all that apply)
Medication History:
BPMH (Best Possible Medication History)
PAC Nurses: List all medications patient taking at home, including
OTC and Herbals. Ensure list is as accurate as possible before
adding to list. This forms the BPMH-Best Possible Medication
History. Thorough medication history taking practices are vital in this
step. Please review interviewing techniques (listed on this poster) for
important steps to consider. Remember this list will form basis for
Admission Orders post-op, after verified with physician.
Frequently Asked Questions!
*For Western Preadmission Clinics and WMH Surgical Inpatients Use Only*
 MA
Directions for Completion
Directions for Completion
Site:
1. Did a doctor change the dose or stop any of your medications recently?
2. Have you changed the dose or stopped any of your medications recently?
3. Have any of the medications been causing side effects?