POLICY:

GDCH will implement and maintain a process to obtain and document a complete list of a patients current medications upon admission. Medication reconciliation is a multidisciplinary process between Nursing, the Pharmacist and the physician with patient/family involvement. Medication reconciliation/verification will be performed:

Upon admission/entry into GDCH, i.e., Emergency Department, Surgery, Direct Admits When a patient is transferred or referred to another setting, service, practitioner or level of care within or outside of this organization Any transition of care where new medications are ordered or existing orders are rewritten (as defined by the organization) At the time of discharge:

Medication reconciliation at the time of discharge avoids therapeutic duplication, drug interactions and omissions of medications that may have been discontinued or placed on hold during the patients hospitalization.

The nurse completing the admission assessment will obtain and document the patients current medications taken at home. These medications will be listed on the Medication Reconciliation/Verification Form.

Pharmacy consultation shall be required for:

Patients taking high-risk medications Patients taking anticonvulsants Patients taking more than ____ medications

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When a patient reports abnormal doses Other

Physicians shall review the Medication Reconciliation/Verification Form in order to make decisions about drug therapy and to document the reason(s) to discontinue, change and/or hold medications. The complete list of the patients medications will be communicated to the next provider of service when the patient is referred or transferred to another setting, service, practitioner or level of care within or outside of GDCH.

Communication of the up-to-date reconciled medication list to the next patient care provider is documented in the patients medical record. The next provider of service will compare the medications on the Medication Reconciliation/Verification Form and the patients MAR from the sending unit to any new medications ordered. At the time of transfer to another healthcare facility, the next provider of service shall be informed on how to obtain clarification on the list of reconciled medications, i.e., phone number of transferring patient care unit documented in the patients medical record.

Reconciliation of medications for non-urgent medications will be completed within ________ hours of admission (within 24 hours of admission):

Reconciliation for urgent medications, high-risk medications and those medications with potentially dangerous variances in dosage will be completed within four (4) hours after orders are written. Medications for which the next dose is due to be administered within four (4) hours shall be reconciled within four (4) hours after orders are written.

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Medications that must be reconciled include:

Blood derivatives Diagnostic and contrast agents IV solutions Nutriceuticals Other products designated by the FDA as a drug Over-the counter drugs Herbal and dietary supplements Parenteral nutrition Prescription medications, including inhalers, eye drops, contraceptives, medication patches, PRN medications, etc. Radioactive medications Respiratory therapy-related medications Sample medications Vaccines Vitamins

The attending physician will make any additions, deletions or corrections to the patients medication orders using the physicians order sheet. The Medication Reconciliation/Verification Form shall be placed in a highly visible location within the patients medical record to assure easy accessibility by providers writing orders.

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PROCEDURE:

Admission:

The nurse completing the admission assessment will obtain and document the patients current medications taken at home. These medications will be listed on the Medication Reconciliation/Verification Form. If the patient does not remember all of his/her medications, the family may be asked to bring all of the patients prescriptions to GDCH. The patients medication history may be obtained by:

Family recall Calling the patients pharmacy The patients prescription containers Recent H&P Transfer Records Primary physician

If the patient has a home medication list, photocopy the list and place in the patients medical record The following will be documented on the Medication Reconciliation/Verification Form:

Medication Dose Route Frequency

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Date and time medication last taken Reason for the medication

The RN assigned to the patient will reconcile the admission medication orders with the list of the patients home medications. Reconciliation of medications will include:

Any omissions Any duplications Interactions Dosing errors Name/dose/route confusion

The nurse will notify the patients physician of any variances, i.e., medications on the Medication Reconciliation/Verification Form that do not match the admission orders. Changes in medication orders will be made on the physicians order sheet. The physician should also review the Medication Reconciliation/Verification Form within ____ hours of admission/entry into GDCH. After reviewing the Medication Reconciliation/Verification Form, the physician will sign the form.

Transfer:

Before patient transfer, the RN assigned to the patient will reconcile the medications using:

The patients MAR from the sending unit The Medication Reconciliation/Verification Form against the medications on the transfer orders The transferring RN shall communicate the up-to-date reconciled medication list to the receiving RN. This communication shall be documented in the Nurses Notes.

The receiving RN will complete the medication reconciliation process and notify the physician of any variances.

If any pre-transfer medication is not ordered on the transfer orders, the nurse will contact the physician. The physician will then order the medication or confirm that the omission or change was deliberate.

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The physician should review the Medication Reconciliation/Verification Form and the patients MAR to decide if medications should be continued, discontinued, resumed
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or held upon transfer to another level of care. After reviewing the Medication Reconciliation/Verification Form, the physician will sign the form.

Discharge:

The RN assigned to the patient will review discharge medication orders with the Medication Reconciliation/Verification Form, the patients home medication list and the most recent inpatient orders. Variances will be reported to the physician. All variances must be corrected before the patient is discharged. The physician should also review the Medication Reconciliation/Verification Form and sign accordingly. All discharge medications and instructions are documented on the Discharge Instruction Sheet, with a copy given to the patient/family, and the original placed in the patients medical record.

Patient instructions should include how to take the medications prescribed, the time for the next dose and how long to take any new medications that may be prescribed. Encourage the patient to carry a list of his/her medications at all times and to present this list to all healthcare providers who are providing care to the patient, i.e., pharmacist, primary care physician, follow-up care physician. Patients and families shall be reminded to throw away old lists of medications, and to give all of their physicians and pharmacies the updated list of medications.

Orientation to and continuing education regarding __________________ Hospitals medication reconciliation process will be provided to staff, i.e., Nursing, Pharmacy and the medical staff. The medication reconciliation process will be monitored via performance improvement activities, and changes will be made to improve processes as needed.

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