a formal process of obtaining a complete and accurate list of each patient’s current medications...
TRANSCRIPT
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.
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
Considered High
Risk
0
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
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
Number of Medications Prior to Admission
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
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
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 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
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
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
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
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
• 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)
Penicillin – HivesPeanuts – Anaphylaxis Ibuprofen – GI upset Eggs? - Rxn Unknown
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)
Penicillin – HivesPeanuts – Anaphylaxis Ibuprofen – GI upset Eggs? - Rxn Unknown
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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate suspension
CHANGE ORDER
COMMENTS Last Dose Date/Time D/C CONTINUE CHANGE
• 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)
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate suspension
500mg/125mg(5ml)
CHANGE ORDER
COMMENTS Last Dose Date/Time D/C CONTINUE CHANGE
• Route– po – oral – ng – nasogastric – sc – subcutaneous – im – intramuscular – iv – intravenous
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate suspension
500mg/125mg(5ml)
PO
CHANGE ORDER
COMMENTS Last Dose Date/Time D/C CONTINUE CHANGE
• 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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate suspension
500mg/125mg(5ml)
PO TID
CHANGE ORDER
COMMENTS 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 Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate suspension
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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Amoxicillin/Clavulanate suspension
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
Generic Name Dose Route Frequency Floor Use
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
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 Frequency Floor Use
PRE-ADMISSION MEDICATION
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
Generic Name Dose Route Frequency Floor Use
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
0800hrSep 12
D/C CONTINUE CHANGE
• SPECIAL SITUATION – Medications given at intervals
• Note due date of next dose as well as last dose
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
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
4 Dose Too High 8 Drug Interaction
Interviewed Patient Poor Historian Pharmanet
Prescription containers
Medication List
MAR
Other________________
Date/Time Today’s Date
Caregiver _Jane Smith_ Ph: 987-4321
Pharmacy _ Wal-Mart _ Ph: 987-6543
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
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
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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
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
• Document a Type 1 discrepancy in the “Floor Use” section
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Ramipril
10mg
PO BID
1CHANGE ORDER
Ramipril
5mg
PO
Daily
COMMENTS Last Dose Date/Time D/C CONTINUE CHANGE
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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
Hydrochlorothiazide
25mg
PO QAM
?CHANGE ORDER
Hydrochlorothiazide
12.5mg
PO
QAM
COMMENTS Last Dose Date/Time D/C CONTINUE CHANGE
?
• 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 Frequency Floor Use
PRE-ADMISSION MEDICATION
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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
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”
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
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”
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
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________________
Date/Time Today’s Date
Caregiver _Jane Smith_ Ph: 987-4321
Pharmacy _ Wal-Mart _ Ph: 987-6543
History Documented by Nancy Green
Authorizing Physician v/o Dr. B. Brown/Alana Froese Date/Time Today’s Date
Faxed to Pharmacy
Pages ____ of ____
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
• 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 Frequency Floor Use
PRE-ADMISSION MEDICATION
Hydrochlorothiazide
25mg
PO QAM
2CHANGE ORDER
Hydrochlorothiazide
12.5mg
PO
QAM
COMMENTS Last Dose Date/Time D/C CONTINUE CHANGE
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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
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__
Case Study: Evelyn Smith
– 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
Generic Name Dose Route Frequency Floor Use
PRE-ADMISSION MEDICATION
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________________
Date/Time Today’s Date
Caregiver _Jane Smith_ Ph: 987-4321
Pharmacy _ Wal-Mart _ Ph: 987-6543
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
Case Study: Carol Harrison
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