Medication Reconciliation Policy

SME: Director of Pharmacy
Last Review Date: 01/16/13
Policy:  
All patients will have all medications reconciled within 24 hours of admission. The final outcome of this process is to generate the most accurate medication list that is available.
The staff will obtain information on medications the patient is currently taking when he/she is admitted to HCPC.  Staff will enter the current medication including the name of the drug, frequency, date, purpose, and data source (pill bottle, referral meds, pt/family report) into the Prescription Writer program.  The physician will complete the process via the medication reconciliation section in the Initial Psychiatric Examination (IPE). Please see  Medication Reconciliation Process Flowchart


Purpose:
Medication reconciliation is an interdisciplinary process between Nursing, Medical Staff and Pharmacy that compares the patient’s most current list of home medications against the physician’s orders upon admission, transfer and discharge, addressing discrepancies, thereby decreasing potential Adverse Drug Events (ADEs) and omissions of medication therapy.


Definition:
Medication Reconciliation is the process of verifying, clarifying and reconciling the patient’s most current list of medications against the physician order within 24hrs of admission. It occurs at time of admission, transfer for consultation and discharge.


ADMISSION PROCEDURE:

  1. The admitting/unit staff will obtain the most current list of medications the patient is currently taking (Active Medications). The medication history will include prescribed medications, over the counter medications, herbal, nutriceuticals, or dietary supplements, including dosage, frequencies, routes and data source.   Admitting staff will also review any previous  inpatient discharge summary for medication history. The admitting staff will discontinue all previous medication listed in the Prescription Writer and enter all current medications into Prescription Writer as “Hx Meds” (historical medications).

1.1 The discontinued medications will remain visible, however, only current/active medication will populate the Nursing Assessment and IPE. The physician is responsible for reviewing the patient medication history in the prescription writer.


1.2 If the patient is not a reliable source or the information is questionable, staff will make efforts to clarify information or seek additional data.


1.3 Medications that are brought into the hospital by the patient’s family/guardian after 24 hours will be added in the Prescription Writer by the nurse.

  1. The Admissions staff will deliver the patient’s medications to the Assessment Nurse on the unit or another staff member if the assessment nurse is not available.  Medications from home will be placed in the pharmacy OUTBOX on the units for patients who are admitted directly to the units. Pharmacy picks up medications at regular intervals. The pharmacist will verify the medication upon receipt once they receive an order from the prescribing physician. It is the responsibility of the physician to reconcile the medication list to the physician’s admission orders.

3.1 Medications that are not reordered must be addressed by the physician via the medication reconciliation section of the IPE.

  1. The medication(s) captured on the prescription writer will populate the Nursing Assessment.

4.1 The nurse/physician must check-off (√ ) medication from the Prescription Writer section of the Nursing Assessment in order for the medications to display in the document once submitted.


CONSULTATION TRANSFER PROCEDURE:

  1. Upon patient transfer out of HCPC, staff will provide the next service provider with a summary of the patient’s medications.
  1. Upon return the physician reviews the consultation notes/recommendations for inclusion in the treatment orders as appropriate. If the physician decides not to continue/order recommended medication, the rationale is reflected in the progress note.

DISCHARGE PROCEDURE:
Discharge reconciliation is the process of reviewing the active routine medications at time of discharge as compared to the patient’s discharge medications including prescriptions. The rationale for discontinuing the medication should be included in the discharge progress note. Discharge medications are entered into Sunrise by the physician.

  1. The Physician discharging the patient must reconcile the discharge prescriptions with the initial medication history on the IPE including medications brought from home.
  2. The physician shall be required on discharge to decide what medications the patient should continue taking after discharge including patient’s home medications.
  3. The physician shall be required to write on the discharge prescription what medications, including home medications be given to the patient by Pharmacy upon discharge.   
  4. The physician shall be required on discharge to indicate what medications the pharmacy should keep and destroy.
  5. The nurse compares actual discharge medications and scripts to the orders to ensure that patient is receiving what was intended at time of discharge.
  6. Documentation and communication of discharge medication orders occurs via the Discharge Summary form for the next provider of service when patient is discharged (for MHMRA referred patients).
  7. For Non-MHMRA patients with patient permission, a discharge summary will be sent to the treating physician. If patient does not permit information transmittal, patient will be given a list of discharge meds to take to his/her physician until signed consent to release information is received from the outpatient physician’s office.
  8. Pharmacist compares discharge orders to active orders and discharge note including home medications at time of discharge and notifies the attending physician  of any discrepancy.

Related Standard:
The Joint Commission: National Patient Safety Goal 03.06.01

 

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Harris County Psychiatric Center University of Texas Health Science Center