A formal process of obtaining a complete and accurate list of each patient’s current medications At Admission, Discharge and at all other Transitions

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

This history is used to write admission orders

PREVENTS ERRORS

An accurate medication history is performed after physician

admission order writing

This history is compared to admission orders and any

discrepancies are reconciled

CATCHES ERRORS

Medication History & Orders Form used 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 pre-admit medications and using the

physician’s order sheet for new admission orders

Medication history documented in traditional locations in the patient’s chart

Physician uses usual physician order sheet to write 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

Nurse/Physician/Pharmacy performs medication history at time of admission and prior to admission orders being written

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

• If time permits, set a goal to reconcile as many patients as possible, if not ALL

Assessment of Patient Risk (APR) Tool Reconcile patients who have scored 10 or have been admitted as a result of a drug-

related problem

Assessment of Patient Risk (circle all applicable factors)

Age

0 – 64 years 0

65 – 80 years 1

> 80 years 2

Number of Medications Prior to Admission

0-1 0

2-4 2

5-7 3

8 or more 6

High Risk MedicationsPrior to Admission

Antiseizure 3

Anticoagulant 3

More than two cardiovascular medications 5

Diabetic medications (oral +/- insulin) 2

Is the reason for admission clearly drug-related (e.g. drug toxicity, non-compliance, polypharmacy)?YesNo

Total Score 9

Not considered

High Risk

• 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.


Age

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




Total Score

Considered High

Risk

0


Age

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




Total Score

Considered High

Risk

10

Referral to Clinical Pharmacy Team Recommended/Required? Yes No Unsure Reason for referral: Example #1: Patient experiencing digoxin toxicity Example #2: Scored 12

Form completed by: Alana Froese Date: 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

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: ASSESSMENT of PATIENT RISK (APR) TOOL Assessment of Patient Risk (circle all applicable factors)

0 – 64 years 0 65 – 80 years 1 Age > 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 High Risk Medications Prior to Admission

Diabetic medications (oral +/- insulin)

2

Is the reason for admission clearly drug-related (e.g. drug toxicity, non-compliance, polypharmacy)?

Yes No

Total Score

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, cholesterol meds, digoxin, amiodarone, daily ASA, clopidogrel, diuretics. Do not count anticoagulants as a cardiovascular medication.

Referral to Pharmacist Recommended/Required? Yes No Unsure Reason for referral: Form completed by: 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

Admitted for drug-related problem – excess use of theophylline

Alana FroeseToday’s

Date

Carol Harrison

Definition

A medication history obtained by ahealthcare 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 Reported Clinical Conditions – 1 found: HYPERCHOLESTEREMIA 1999 Mar 01 Patient Reported Adverse Reactions – 2 found: 510645 SULFAMETHOXAZOLE/ TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET 2000 Jul 18 P1/02301 RASH 2043246 PENICILLIN G POTASSIUM WYETH-AYERST CA 10MU VIAL 1996 Jan 01 91/15399 ANAPHYLAXIS

Reported Medication History – 15 of 15 printed: 510645 SULFAMETHOXAZOLE/ TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET 14 @ 2/day TAKE ONE TABLET TWICE DAILY Reversed: 2006 May 30 91/07692 (HARDY) Prescription cancelled by physician 2169126 P-EPHED HCL/ CODEINE/ TRIPROL RATIOPHARM 30-10-2/ 5 LIQUID 250 @ 8.333/day TAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED Filled: 2006 Mar 29 91/03361 (LAVOY) 28053 SULFACETAMIDE SODIUM SCHERING CANADA 10% DROPS 15 @ 2.143/day 2 DROPS IN EACH EYE EVERY 3 HOURS FOR 7 DAYS Filled: 2006 Mar 24 91/03361 (LAVOY) 2213672 FLUTICASONE PROPIONATE GLAXO SMITH KLINE 50MCG SPRAY 120 @ 4/day USE TWO SPRAYS IN EACH NOSTRIL DAILY

Demographics

PHN – Personal Health Number (Care Card #)

Name

Date of Birth

Sex



Clinical conditions

Typically this area is not used

Reported by

Date reported



Allergies and Reactions

Can not guarantee this is an accurate listing of allergies

Reported by:

Date reported

PRACTITIONER CODES

V9 Veterinarian

91 Physician/Surgeon

95 Dentist

P1 Pharmacist

93 Podiatrist

98 Midwife



Dispensing History

-Most recent reported first

-Drug by generic name(s)

-Drug Identification Number (DIN)

-Quantity

-Sig (Instructions)

-Physician

-Date Filled or Reversed

• 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 P-EPHED HCL/CODEINE/TRIPROL RATIOPHARM 30-10-2/5 LIQUID250 @ 8.333/day TAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED

Filled: 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 QUININE SULFATE NOVOPHARM LTD 300MG CAPSULE 60 @ 1/day TAKE ONE CAPSULE AT BEDTIME AS NEEDED FOR LEG CRAMPS Filled: 2005 Dec 04 91/02295 (MACKAY)

• Watch for specialty formulation information

2014165 THEOPHYLLINE ANHYDROUS PURDUE PHARMA 400MG TAB SR 24H 90 @ 1/day TAKE ONE TABLET ONCE DAILY Filled: 2006 Mar 04 91/02295 (MACKAY)

2007959 ACETYLSALICYLIC ACID PHARMASCIENCE 81MG TABLET DR90 @ 1/day TAKE ONE TABLET ONCE DAILY Filled: 2006 Mar 04 91/02295 (MACKAY)

02202441 OXYCODONE PURDUE PHARMA 10MG TABLET CR 56 @ 2/day TAKE ONE TABLET EVERY 12 HOURS Filled: 2006 May 22 91/05568 (BROWN)

2237280 VENLAFAXINE WYETH CANADA 75MG CAPSULE XR60 @ 1/day TAKE ONE CAPSULE ONCE DAILY Filled: 2006 Apr 15 91/05568 (BROWN)

Sustained Release

Controlled Release

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


• 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

• 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

NKA

Allergies/Intolerances (specify reactions)

Penicillin – HivesPeanuts – Anaphylaxis Ibuprofen – GI upset Eggs? - Rxn Unknown

Weight

______ kg lbs

Estimated Actual

Height

______ 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

(specify reactions)


Weight

__76.8___ kg lbs

Estimated Actual

Height

______ m / cm ft / in

Estimated Actual

NKA

Allergies/Intolerances

• 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

(specify reactions)


Weight

__76.8___ kg lbs

Estimated Actual

Height

_5’ 6’’_ m / cm ft / in

Estimated Actual

Allergies/Intolerances

NKA

• 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

Generic Name Dose Route Frequency Floor Use

PRE-ADMISSION MEDICATION

Amoxicillin/Clavulanate

CHANGE ORDER

COMMENTS Last Dose Date/Time D/C CONTINUE CHANGE

• 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



Amoxicillin/Clavulanate suspension

CHANGE ORDER


• 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)




500mg/125mg(5ml)

CHANGE ORDER


• Route– po – oral – ng – nasogastric – sc – subcutaneous – im – intramuscular – iv – intravenous




500mg/125mg(5ml)

PO

CHANGE ORDER


• 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




500mg/125mg(5ml)

PO TID

CHANGE ORDER


• 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




500mg/125mg(5ml)

PO TID

CHANGE ORDER

COMMENTS

2 days of 7 days completed Last Dose Date/Time D/C CONTINUE CHANGE

• Comments – Indication as reported by patient if known– Adverse events experienced?– Physician directed patient to reduce dose

at last office visit – Non-compliance




500mg/125mg(5ml)

PO TID

CHANGE ORDER

COMMENTS

Acute Sinusitis Non-compliance: taking bid 2 days of 7 days completed

Last Dose Date/Time 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



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

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



Ibuprofen 400mg

PO TID PRN

CHANGE ORDER

COMMENTS

Headaches 1-2 episodes/month Last Dose Date/Time

1200hrSep 12

D/C CONTINUE CHANGE

SPECIAL SITUATIONS• Medications given in cycles

– Didrocal kit – note where patient is in 90 day cycle



Etidronate 400mg/Calcium 1250mg Kit

1 tab

PO Daily

CHANGE ORDER

COMMENTS

Osteoporosis 56 tablets left in 90 day kit

Last Dose Date/Time

0800hrSep 12

D/C CONTINUE CHANGE

• SPECIAL SITUATION – Medications given at intervals

• Note due date of next dose as well as last dose



Cyanocobalamin 1,000 mcg

(1ml)

IM Monthly

CHANGE ORDER

COMMENTS

Anemia Next dose due: Oct 21Last Dose Date/Time

0800hr Sep 21

D/C CONTINUE CHANGE

• 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 InformationVerification 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

Interviewed Patient Poor Historian Pharmanet

Prescription containers

Medication List

MAR

Other________________

Date/Time

Caregiver _Jane Smith_ Ph: 987-4321

Pharmacy _ Wal-Mart _ Ph: 987-6543

History Documented by

• Sign your name • Record date and time

Source of InformationVerification Codes

1 Indication 5 Wrong Drug

2 No Indication 6 Non-Compliance

3 Dose Too Low 7 Adverse Event


Interviewed Patient Poor Historian Pharmanet

Prescription containers

Medication List

MAR

Other________________

Date/Time Today’s Date



History Documented by Alana Froese

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


• 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

ADRInappropriate duplication of therapeutic

class or active ingredient

• DOSE TOO LOW/DURATION TOO SHORT

Drug dose too low (sub-therapeutic)Dosage regime not frequent enoughDuration 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

indicationDrug 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 errorDispensing 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

• If there is no change, add the verification code “1” to the continue box

• Document a Type 0 discrepancy in the “Floor Use” section



Ramipril

10mg

PO BID

0CHANGE ORDER

COMMENTS Last Dose Date/Time D/C CONTINUE

1CHANGE

• 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




Ramipril

10mg

PO BID

1CHANGE ORDER

Ramipril

5mg

PO

Daily


4

• 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



Hydrochlorothiazide

25mg

PO QAM

?CHANGE ORDER

Hydrochlorothiazide

12.5mg

PO

QAM


?

• 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




Ramipril

10mg

PO BID

1CHANGE ORDER

Nil

COMMENTS Last Dose Date/Time D/C

7CONTINUE 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



Ramipril

10mg

PO BID

?CHANGE ORDER

Nil

COMMENTS Last Dose Date/Time D/C

?CONTINUE CHANGE

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

• 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”



Hydrochlorothiazide

25mg

PO

QAM

ORDER AT ADMISSION

Hydrochlorothiazide

12.5mg

PO

QAM

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”



Ramipril

10mg

PO

BID

ORDER AT ADMISSION

Nil

COMMENTS

Hypertension Continue admission order

Revert to pre-admission

order

• Physician/Pharmacist to sign and date at bottom of form• Ideally, to be placed in patient’s chart and processed as

an order

Source of Information Discrepancy Types

Undocumented Intentional Resolution: Continue admission order

Unintentional Resolution: Revert to pre- admission order

Interviewed Patient Poor Historian Pharmanet Prescription containers Medication List MAR Other________________




History Documented by Nancy Green

Authorizing Physician v/o Dr. B. Brown/Alana Froese Date/Time Today’s Date

Faxed to Pharmacy

Pages ____ of ____


• 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

• 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



Hydrochlorothiazide

25mg

PO QAM

2CHANGE ORDER

Hydrochlorothiazide

12.5mg

PO

QAM


4

• If an Unintentional Discrepancy is identified• Indicate a Type 3 discrepancy in the Floor Use box• In this situation, the physician reverted to the pre-

admission order indicating a true error occurred



Ramipril

10mg

PO BID

3CHANGE ORDER

Nil

COMMENTS Last Dose Date/Time D/C CONTINUE

1CHANGE

• 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

Authorizing Physician Dr. B. Brown/Alana Froese Date/Time Today’s Date

Faxed to Pharmacy

Pages __1__ of __1__


– The final step! – Document resolutions on Medication

History form – Return to Technician to compile

statistics

• 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



Ramipril

10mg

PO

BID

UC

RN

ORDER AT ADMISSION

Nil

COMMENTS

Hypertension Continue admission order

Revert to pre-admission

order

• Unit Clerk/Nurse will indicate number of pages & check Faxed to Pharmacy Box when sending to pharmacy

Source of Information Discrepancy Types

Undocumented Intentional Resolution: Continue admission order

Unintentional Resolution: Revert to pre- admission order

Interviewed Patient Poor Historian Pharmanet Prescription containers Medication List MAR Other________________




History Documented by Nancy Green

Authorizing Physician v/o Dr. B. Brown/Alana Froese Date/Time Today’s Date

Faxed to Pharmacy

Pages __1___ of __1___

• You have just completed a BPMH1. Compare the Physician Orders to the Medication

History1. Note: you are unable to glean additional information

regarding the rational to therapeutic changes from other sections in the chart

2. Document Discrepancies on Medication History form

3. Complete Discrepancy Clarification & Resolution (DCR) form

4. Call physician to clarify discrepancies and document on DCR form

5. 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 pre-

admit 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

Documents

A formal process of obtaining a complete and accurate list of each patient’s current medications At Admission, Discharge and at all other Transitions