medication reconciliation: discharge timeout casey mashl, pharm.d mitchell chan, pharm.d pgy1...

Medication Reconciliation: Discharge Timeout

Casey Mashl, Pharm.DMitchell Chan, Pharm.D

PGY1 Residents

Overview• Medication reconciliation is a vital part of patient

care and safety• Maintains continuity of care• Ensures appropriate

continuation/discontinuation of medications at admission and discharge

• Discharge timeout process – Accountability– Continuity– Safety

What is Med Rec?

• Medication reconciliation is a process to determine what Rxs, OTCs, herbals/supplements a patient is currently on

• Why do we need to do this?– Continue regimen while in the hospital– Determine if any medications are contributing to

the patient’s condition• Possibly increase/decrease or discontinue meds

How is Med Rec Used?

• Physicians review med rec prior to entering admission orders– If med rec is entered incorrectly, inpatient

medications can be continued incorrectly and may lead to patient harm

– Inpatient and discharge medications are also chosen from the med rec

Importance

• An accurate med rec allows for a safe transition of care both into the hospital and discharge to home

• When we know exactly what the patient taking at home, it allows for the highest level of medication optimization

Medication Reconciliation• Performed by– Pharmacist– Pharmacist Interns

• Multi-step process1.Review home medication list & External med history2.Perform patient interview3.Submit correct med rec into EMR4.Compare home meds with inpatient meds5.Contact ordering physician or practitioner

Medication Reconciliation

• IMAGE OF BAD MED REC

Discount Double Check

Discharge Timeout= Discharge Double Check

• Estimate of 2 in 5 patients in the hospital has discrepancies in their medication reconciliation that a pharmacist can correct and intervene1

• 56% reduction in chart discrepancies at discharge2

• Multi-step– Nurse-nurse, nurse-pharmacist check

• Admission• Discharge

1. Bishop MA, Cohen BA, Billings LK, Thomas EV. Reducing errors through discharge medication reconciliation by pharmacy services. Am J Health Syst Pharm. 2015;72(17 Suppl 2):S120-6.

2. Ruggiero J, Smith J, Copeland J, Boxer B. Discharge Time Out: An Innovative Nurse-Driven Protocol for Medication Reconciliation. Medsurg Nurs. 2015;24(3):165-72.

Discharge Timeout Form

Conclusions

• Med rec is vital in maintaining continuity of care and patient safety

• Discharge time out process aims to reduce the number of chart discrepancies and negative medication-related patient outcomes

• South County Hospital Discharge Timeout update