Medication Reconciliation

1
Medication Reconciliation

• Johns Hopkins Hospital
• March 2006
• Bob Feroli, PharmD, FASHP

2
Transition of Care

• Patients previous home medications are not
  considered when writing discharge orders. Patient
  is discharged on Zocor(simvastatin).
• At home, patient starts Zocor and continues to
  use previously prescribed Lipitor(atorvastatin).
  
• Eleven days later, patient is admitted with
  severe rhabdomyolysis secondary to statin
  overdose.

3
Transition of Care

• Patient with Parkinson's disease is admitted to
  an ICU for an acute episode unrelated to
  Parkinsons disease.
• Initial care is focused on the acute episode and
  anti-Parkinsons drugs are not used.
• Patient is transferred to general care unit,
  Home therapy is not considered and
  anti-Parkinsons therapy is not started.
• Patient develops severe Parkinsonian symptoms.

4
Transition of Care

• Discharge orders for 33 randomly selected ICU
  patients were reviewed by an RN in context with
  the patients home medications and ICU meds.
• Potential discrepancies were brought to the
  attending of the ordering physician.
• Discharge orders for 31 of 33 patients (94)
  were changed.
• Pronovost P, et al. J Crit Care 18(4)201-205,
  2003

5
Transition of Care

• Errors can occur when a patients care is passed
  from one group to the next
• Medication therapy may be inappropriately
• Continued
• Omitted
• Changed
• Duplicated

6
Medication Reconciliation

• Reassessment of medication therapy as a patient
  moves from one level of care to the next. When
  properly done will
• Support continuity of care
• Help to avoid medication errors
• JHH quality improvement priority for FY06
• Documentation is mandated by JCAHO
• Effective Jan 1, 2006

7
Admission
Transfer
Discharge
8
Admission
Transfer
Discharge
9
Admission
Transfer
Discharge
Eclipsys SCC?
10
Admission
Transfer
Discharge
ICUs IMCs Adult Onc Nel-7
Eclipsys SCC?
11
Admission
Transfer
Discharge
Eclipsys SCC?
YES
12
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
YES
13
Admission
Transfer
Discharge

• Home Meds
• Rx medications
• Sample medications
• Herbal remedies
• Vitamins
• Nutriceuticals
• OTC drugs

Eclipsys SCC?
RN enters home medications into Eclipsys
YES
14
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
YES
15
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
Clerical Assoc. or RN Prints Home Medication
Reconciliation form
YES
16
Admission
Transfer
Discharge
Eclipsys?
Enter home medications into Eclipsys
Print Home Medication Reconciliation form
YES
17
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
Clerical Assoc. or RN Prints Home Medication
Reconciliation form
YES
18
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
Clerical Assoc. or RN Prints Home Medication
Reconciliation form
YES
No
Fill out Home Medication Reconciliation form
19
Admission
Transfer
Discharge
Eclipsys SCC?
Enter home medications into Eclipsys
Print Home Medication Reconciliation form
No
Fill out Home Medication Reconciliation form
20
Admission
Transfer
Discharge
Initial Med List Entered by Patient Pt family
member Nurse Physician Pharmacist other
Eclipsys SCC?
Enter home medications into Eclipsys
Print Home Medication Reconciliation form
No
Fill out Home Medication Reconciliation form
21
Admission
Transfer
Discharge
Provides one location for the home med
list Initial Screening Form HP See home med
reconciliation form
Eclipsys SCC?
Enter home medications into Eclipsys
Print Home Medication Reconciliation form
No
Fill out Home Medication Reconciliation form
22
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
Clerical Assoc. or RN Prints Home Medication
Reconciliation form
YES
No
Fill out Home Medication Reconciliation form
23
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
Clerical Assoc. or RN Prints Home Medication
Reconciliation form
YES
No
Prescriber considers home med list when
developing admission orders
Fill out Home Medication Reconciliation form
24
Admission
Transfer
Discharge
Eclipsys SCC?
RN enters home medications into Eclipsys
Clerical Assoc. or RN Prints Home Medication
Reconciliation form
YES
No
Prescriber considers home med list when
developing admission orders
Prescriber signs Home Medication Reconciliation
form
Fill out Home Medication Reconciliation form
25
Admission
Transfer
Discharge
Eclipsys SCC?
Enter home medications into Eclipsys
Print Home Medication Reconciliation form
YES
No
Prescriber considers home med list when
developing admission orders
Prescriber signs Home Medication Reconciliation
form
Fill out Home Medication Reconciliation form
26
Admission
Transfer
Discharge
Eclipsys SCC?
Enter home medications into Eclipsys
Print Home Medication Reconciliation form
YES
No
Prescriber considers home med list when
developing admission orders
Prescriber signs Home Medication Reconciliation
form
Fill out Home Medication Reconciliation form
Place form into chart behind Med Administration
tab
27
Admission
Transfer
Discharge
Eclipsys SCC?
Enter home medications into Eclipsys
Print Home Medication Reconciliation form
YES
No
Prescriber considers home med list when
developing admission orders
Prescriber signs Home Medication Reconciliation
form
Fill out Home Medication Reconciliation form
Place form into chart behind Med Administration
tab
28
Admission
Transfer
Discharge
29
Admission
Transfer
Discharge
30
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
POE and/or Eclipsys
31
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
32
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
POE and/or Eclipsys
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
33
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
34
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Non-Eclipsys and Non-POE
35
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Non-Eclipsys and Non-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
36
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
37
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
38
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber considers Home Med List and Meds
used just prior to transfer When developing
transfer orders
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
39
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber considers Home Med List and Meds
used just prior to transfer When developing
transfer orders
Prescriber Signs Transfer Reconciliation form
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
40
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber Signs Transfer Reconciliation form
41
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber Signs Transfer Reconciliation form
42
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber considers Home Med List and Meds
used just prior to transfer When developing
transfer orders
Prescriber Signs Transfer Reconciliation form
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
43
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber considers Home Med List and Meds
used just prior to transfer When developing
transfer orders
Prescriber Signs Transfer Reconciliation form
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
Place form into chart behind Med Administration
tab
44
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber considers Home Med List and Meds
used just prior to transfer When developing
transfer orders
Prescriber Signs Transfer Reconciliation form
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
Place form into chart behind Med Administration
tab
45
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber considers Home Med List and Meds
used just prior to discharge When developing
discharge orders
Prescriber Signs Transfer Reconciliation form
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
Place form into chart behind Med Administration
tab
46
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber Signs Transfer Reconciliation form
47
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber Signs Transfer Reconciliation form
48
Admission
Transfer
Discharge
Sending Unit
Receiving Unit
Clerical Assoc. or Nurse sends patient
specific Transfer Reconciliation form
POE and/or Eclipsys
Prescriber considers Home Med List and Meds
used just prior to discharge When developing
discharge orders
Prescriber Signs Transfer Reconciliation form
No-Eclipsys and No-POE
Clerical Assoc. or Nurse sends non-patient
specific Transfer Reconciliation form
Place form into chart behind Med Administration
tab
49
Medication ReconciliationNext Steps

• Improve compliance with current system
• Automate reconciliation process
• Improve reconciliation in outpatient sector