Prescriber EducationMedication Reconciliation Patient Safety Initiative

Why Med Rec?It is a patient safety initiative

• Reduction of adverse events at key transitions of care (adm, transfer, disch)

• One of the WHO top 5 patient safety initiatives²

Structured communication process that formalizes what we already do

Required for Accreditation• HC professionals partner with clients, families and

caregivers for accurate and complete transfer of medication information¹

¹Accreditation Canada ROP²World Health Organization

Admission

Gleason et al (2010). MATCH study.• 85% med errors originate in medication histories, almost

half were omissions

• Risk Factors (age, #meds). (J Gen Int Med)

Vira et al (2006). • 60% admitted pts had unintended discrepancies.

• 18% clinically significant

• 75% of these were intercepted by MedRec before pts suffered harm (Quality and safety in healthcare).

Discharge

Intervention (MedRec) vs. control groups• 33.5% medication discrepancies at discharge

with MedRec• 59.6% in control group (Walker et al, 2009 Arch Int Med)

How does it work?

BPMH Reconcile Document Review at transfer

MedRec at Discharge Audit

• Best Possible Medication History (BPMH) is the cornerstone of the MedRec admission process.

• Home medication history• Reference point for clinical decisions to continue,

discontinue or modify home medications during key transitions of care

• Medication orders on admission

(once reconciled and signed by prescriber)

Ideally completed within 24h of admission

Admission

Sources used to obtainhistory

Date/Time the historycompleted

All prescribed homeMedications [including Over-the-counter (OTC) medicationsif they were PRESCRIBED to pt.]

Self-prescribed Medications – (for information purposes only)

Additional Comments (information purposes only)

Reconciliation section(Prescriber Use Only)

Prescriber signs & includes date and time of reconciliation

Page #s

BPMH

BPMH

Goal: Complete, accurate list of patient’s HOME medications• Document how the patient is ACTUALLY taking the

medication…do not assume

• If pt taking it differently than prescribed, note how it was prescribed in the Comments section.

•Use generic drug name whenever possible

BPMH - Sources

Ideally, validate the history using at least TWO (2) sources of information.

• Pt/Family, bubble packaging, med list, Netcare PIN, MAR from another facility, Community Pharmacy printout, etc.

• 2 sources may not always be available

Netcare Medication Profile/PIN is only ONE of many potential sources and is not always accurate!

Eye drops Ear drops

Medicated creams/

ointments

Inhalers

Injections

Nasal sprays

Medicated patches

Interview Tips: “HEAD TO TOE”

When do I NOT need to complete a BPMH?

• Direct admits from another facility• If they already have a completed admission BPMH

(copy to be faxed to your site).

• The BPMH will not serve as inpatient orders, only as a history/reference

• A new BPMH does not need to be completed.

• Write admission orders per usual process pre-MedRec implementation (using other facility’s BPMH and transfer orders as reference)

• The admitting prescriber will be completing the BPMH for all non-elective admissions (i.e. ER admits and direct admits. Exception: Vascular Direct admits during clinical pharmacist hours will be

completed by Pharmacist, if available)

• All elective admissions will have a BPMH previously completed by a Pharmacy Technician in Preadmission Clinic (PAC)

• See “How to Fill Out a BPMH Tool” and more on CompassionNet

• www.compassionnet.ca• Care and Safety → Medication Management Initiatives

→Medication Reconciliation

How to Complete the BPMH Tool

• Even if a medication is an OTC product, it is still written in the top/main section IF it has been PRESCRIBED/recommended by a licensed health care professional.

• If it was not prescribed to the patient, document in the Self-Prescribed Section (see next slide)

BPMH Documentation:

Self-Prescribed Medications Section

• Any medication(s) the patient independently decided to take.

• If you would like any of these to be continued in hospital, additionally write an order for them on the Patient Care Order (pink) sheets.

Reconciling the BPMH

This is the section where the prescriber orders to continue, discontinue, or change the HOME medications, and WHY

What do the columns mean?“Continue”:

The prescriber would like the medication to continue in hospital exactly as written. This serves as a Prescriber’s Order.

“Discontinue”:

The medication will be stopped. Please include REASON.

“Change”:

The medication will still be ordered, but in a different way. (Changed dose, route and/or frequency).

• Please include REASON. • Additionally, write the new order on a Patient Care Order

(pink) sheet.

What if I discover after the BPMH has been reconciled and processed as orders that a HOME medication was missed on the original list?

• New information may be learned about the patient’s HOME medications after the BPMH is processed.

• Because this history is referred to at all key transition points, it should be as accurate as possible.

• Any licensed health care professional may document an addendum. Write “Late Entry” along with the name, dose, frequency and route of the medication

• Date, time and sign your entry

• If there is no room, start a new admission BPMH page and renumber all associated pages

Late Entries/Addendums

•As usual, Prescriber will be notified to address the discrepancy

•NOT to be processed/scanned to pharmacy again

• Any orders needed are to be written on the Patient Care Order (Pink) sheets

Late Entries/Addendums

SCANNEDC

Where will the BPMH be kept?• The BPMH will be kept in the Patient Care Orders Section (pink

sheets) of the chart

• It will be the top page of the section and be placed opposite the pink sheets

•This is so the BPMH is easily accessible for review when the prescriber writes orders

What are my responsibilities?• Admitting prescriber completes:

• HOME medications “History” (left) section for all non-elective admissions (ER and direct admits) within 24h of admission*.

*See exceptions on flow map

• All elective patients will have a BPMH previously completed in PAC by a Pharmacy Technician

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When to reconcile?It is at the discretion and clinical judgment of the admitting prescriber whether to complete the Prescriber Reconciliation section at admission (pre-op) or to wait until post-op

This will depend on imminence of the surgery, etc.

In either case, the BPMH can only be reconciled and used as orders ONCE (pre-op OR post-op, not both).

• Write any other medication and non-medication orders, including any changed home medications, on a regular Patient Care Order (pink) sheet.

• Document and address late entries (if other staff discover an addendum, they will notify you, per usual practice.)

What are my responsibilities?

Tip

Any other place the medication history needs to be listed; “See BPMH” may be written or stamped.

Transfer

Transfer

A change in service and/or level of care within the facility

• ex. Grey Nuns Surgery to Grey Nuns Internal Medicine 

• Attending physician rotation (on same service) is not considered a transfer

• Within-service bed changes are not considered transfers

Transfer Discharge

Patient remains within the facility

• From Unit To Unit

Patient physically leaves the facility

• Out of the Hospital Setting (ex. Home, group home, independent living) OR

• Out of a facility to another healthcare facility (ex. Grey Nuns Hospital to Youville Home)

Transfer vs. Discharge MedRec

What do I complete on transfer?

A sticker will be used.

What about IMCU Transfer to Ward?

(GNCH Only)

Prescriber will check off this boxon the Preprinted Orders

What are my responsibilities?• Review BPMH and current medications prior to patient transfer within-hospital.

• Place MedRec Transfer sticker on Patient Care Orders (pink) sheet along with any transfer orders you are writing.

• Sign, date and time the sticker.

Discharge

Or Medication Profile

Please Note:

********** The MedRec Discharge Tool will be completed for Vascular Surgery discharges ONLY at this time, and only when the Vascular Pharmacist is on duty and able to assist with completion. **********

Discharge MedRec Tool

Date and Time

Prescribers Orders

Bubble Packaging Requested

Discharge MedicationList

DiscontinuedMedications (Prescribedand Self-prescribed)

Prescriber Name andSignatureUnit Contact Information

Prescription/Quantity

Page #s

Other Important Information

Community Pharmacy Information

Complete and accurate list of discharge medications

Plus a list of discontinued home medications

Once signed by prescriber:

• Discharge medication orders (if patient going to another facility) and/or

• Prescription (if a quantity specified)

• Replaces current discharge prescription process

Why a Discharge MedRec Tool?

• Lists all medications the patient is to take after being discharged from the site.

• Beside each medication, it is indicated whether the medication is:• Continue – Unchanged PRE-ADMISSION medication

• Changed – PRE-ADMISSION medication has been changed during hospitalization (dose, route, or frequency). Include rationale in space provided.

• New – New medication started while in hospital. Include rationale in space provided.

• In the “Discontinued HOME Medications” section (see stop sign), any HOME medications that were discontinued during hospitalization and are NOT to be given on discharge, are listed.

Discharge Tool

• When a prescription is required, quantity +/- refills is indicated in the designated columns

• If no qty or refills are required, strike a line through the column(s)

• Triplicate (TPP) medications should still be listed on the discharge tool to ensure the list is complete

• Additionally, a Triplicate Prescription is required (unless the patient is going directly to another inpatient facility)

FYI: Instructions are also on the back of the white copy (top copy) of the form

Discharge Tool

Discharge Tool: Two-ply

White ply:

• Chart/Prescription copy. Can be faxed to community pharmacy, etc.

Yellow ply:

• Copy for patient/caregiver for their records

Discharge directly to another facility

• Discharge tool serves as discharge medication orders that can be faxed to the next facility.

• All other non-medication related discharge orders should be written as per usual on the Patient Care Order (pink) sheets.

• The admission BPMH should be faxed to the receiving facility along with the Discharge Tool.

• Check off “Send Admission BPMH”• This provides the receiving facility with an understanding of

the patient’s home medications as well.

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• Discharging Vascular Prescriber to liaise with Vascular Pharmacist who will assist with completion of the tool when available on duty.

• (Usual hours M-F 0800h-1530h)

• Sign/date/time the MedRec Discharge Tool (Prescriber must complete final review/signature).

• If Clinical Pharmacist is unavailable, Discharge MedRec will not be mandated.

What are my responsibilities?

Tip

Any other place the discharge medications need to be listed, “See MedRec” may be written or stamped.

MedRec ResourcesCompassionNet

• Internal (How To) and External Resources

• MedRec Policy VII-B-235

• On Deck with MedRec Newsletters

MedRec Info Binders• Binder will be at unit clerk’s desk

MedRec Flow Sheet/Responsibilities Poster

• Will be posted on your unit

MedRec Project Team• medication.management@covenanthealth.ca

MedRec Page: CompassionNet1. Go to www.compassionnet.ca

2. Click “Care & Safety”

3. Then click on

4. Then click on

When does implementation begin?

Monday June 15, 2015

Until then, follow current unit practices already in place.

Local Implementation• Begin with “Kick-Off Event” – see posters

• Implementation: • Week One: Project Team is physically present on site

for first week and via pagers Support the MedRec Champions Coaching & guidance for local staff on the use of MedRec

tools/processes

• Week Two: Project Team available remotely via pagers• Two weeks in: auditing commences

• End with “Celebration Event” – see posters

Questions/Feedback?

• Local Unit MedRec Champions

• MedRec Team • During implementation dates: in-person and via pagers;

(pager hours will be posted on the units)• Pager #1: (780) 445-5398

• Pager #2: (780) 969-9879

• Any time at: medication.management@covenanthealth.ca