Medication Reconciliation Johns Hopkins Hospital March 2006 Bob Feroli, PharmD, FASHP.

Medication ReconciliationMedication Reconciliation

Johns Hopkins HospitalJohns Hopkins HospitalMarch 2006March 2006

Bob Feroli, PharmD, FASHPBob Feroli, PharmD, FASHP

Transition of Care Transition of Care

Patient’s previous home medications are not Patient’s previous home medications are not considered when writing discharge orders. considered when writing discharge orders. Patient is discharged on ZocorPatient is discharged on Zocor®(simvastatin).(simvastatin).

At home, patient starts ZocorAt home, patient starts Zocor® and continues and continues to use previously prescribed Lipitorto use previously prescribed Lipitor®(atorvastatin).(atorvastatin).

Eleven days later, patient is admitted with Eleven days later, patient is admitted with severe rhabdomyolysis secondary to “statin” severe rhabdomyolysis secondary to “statin” overdose.overdose.

Transition of Care Transition of Care

Patient with Parkinson's disease is admitted to an Patient with Parkinson's disease is admitted to an ICU for an acute episode unrelated to Parkinson’s ICU for an acute episode unrelated to Parkinson’s disease.disease.

Initial care is focused on the acute episode and Initial care is focused on the acute episode and anti-Parkinson’s drugs are not used. anti-Parkinson’s drugs are not used.

Patient is transferred to general care unit, Patient is transferred to general care unit, “Home” therapy is not considered and anti-“Home” therapy is not considered and anti-Parkinson’s therapy is not started. Parkinson’s therapy is not started.

Patient develops severe Parkinsonian symptoms.Patient develops severe Parkinsonian symptoms.

Transition of Care Transition of Care

Discharge orders for 33 randomly selected Discharge orders for 33 randomly selected ICU patients were reviewed by an RN in ICU patients were reviewed by an RN in context with the patient’s home context with the patient’s home medications and ICU meds. medications and ICU meds.

Potential discrepancies were brought to Potential discrepancies were brought to the attending of the ordering physician.the attending of the ordering physician.

Discharge orders for 31 of 33 patients Discharge orders for 31 of 33 patients (94%) were changed. (94%) were changed.

Pronovost P, et al. J Crit Care 18(4):201-205, 2003 Pronovost P, et al. J Crit Care 18(4):201-205, 2003

Transition of Care Transition of Care

Errors can occur when a patient’s care Errors can occur when a patient’s care is passed from one group to the nextis passed from one group to the next

Medication therapy may be Medication therapy may be inappropriately:inappropriately: ContinuedContinued OmittedOmitted ChangedChanged DuplicatedDuplicated

Medication ReconciliationMedication Reconciliation Reassessment of medication therapy as Reassessment of medication therapy as

a patient moves from one level of care a patient moves from one level of care to the next. When properly done will:to the next. When properly done will: Support continuity of careSupport continuity of care Help to avoid medication errorsHelp to avoid medication errors

JHH quality improvement priority for JHH quality improvement priority for FY06FY06

Documentation is mandated by JCAHODocumentation is mandated by JCAHO Effective Jan 1, 2006Effective Jan 1, 2006

Admission

Transfer Discharge

Admission

Transfer Discharge

Admission

Transfer Discharge

EclipsysSCC?

Admission

Transfer Discharge

EclipsysSCC?

ICUsIMCs

Adult OncNel-7

Admission

Transfer Discharge

EclipsysSCC?

YES

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

EclipsysSCC?

YES

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

EclipsysSCC?

YES

Home Meds

Rx medicationsRx medicationsSample medications Sample medications

Herbal remediesHerbal remediesVitaminsVitamins

NutriceuticalsNutriceuticalsOTC drugsOTC drugs

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

EclipsysSCC?

YES

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

Clerical Assoc. or RN Prints

Home Medication Reconciliation form

EclipsysSCC?

YES

Admission

Transfer Discharge

Enter “home” medications into Eclipsys

Print Home Medication

Reconciliationform

Eclipsys? YES

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

Clerical Assoc. or RN Prints

Home Medication

Reconciliation form Eclipsys

SCC?YES

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

Clerical Assoc. or RN Prints

Home Medication

Reconciliation form

Fill out Home Medication

Reconciliationform

EclipsysSCC?

YES

No

Admission

Transfer Discharge

Enter “home” medications into Eclipsys

Print Home Medication

Reconciliationform

Fill out Home Medication

Reconciliationform

EclipsysSCC?

No

Admission

Transfer Discharge

Enter “home” medications into Eclipsys

Print Home Medication

Reconciliationform

Fill out Home Medication

Reconciliationform

EclipsysSCC?

No

Initial Med ListEntered by:

PatientPt family member

NursePhysician

Pharmacistother

Admission

Transfer Discharge

Enter “home” medications into Eclipsys

Print Home Medication

Reconciliationform

Fill out Home Medication

Reconciliationform

EclipsysSCC?

No

Provides onelocation for thehome med list

Initial Screening FormH&P

“See home med reconciliation form”

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

Clerical Assoc. or RN Prints

Home Medication Reconciliation form

Fill out Home Medication

Reconciliationform

EclipsysSCC?

YES

No

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

Prescriber considershome med list when developing admission

orders

Clerical Assoc. or RN Prints

Home Medication Reconciliation form

Fill out Home Medication

Reconciliationform

EclipsysSCC?

YES

No

Admission

Transfer Discharge

RN enters “home” medications into Eclipsys

Prescriber considershome med list when developing admission

orders

Prescriber signs“Home” MedicationReconciliation form

Clerical Assoc. or RN Prints

Home Medication Reconciliation form

Fill out Home Medication

Reconciliationform

EclipsysSCC?

YES

No

Admission

Transfer Discharge

Enter “home” medications into Eclipsys

Prescriber considershome med list when developing admission

orders

Prescriber signs“Home” MedicationReconciliation form

Print Home Medication

Reconciliationform

Fill out Home Medication

Reconciliationform

EclipsysSCC?

YES

No

Admission

Transfer Discharge

Enter “home” medications into Eclipsys

Prescriber considershome med list when developing admission

orders

Prescriber signs“Home” MedicationReconciliation form

Print Home Medication

Reconciliationform

Fill out Home Medication

Reconciliationform

EclipsysSCC?

YES

No

Place form intochart behind

Med Administration tab

Admission

Transfer Discharge

Enter “home” medications into Eclipsys

Prescriber considershome med list when developing admission

orders

Prescriber signs“Home” MedicationReconciliation form

Print Home Medication

Reconciliationform

Fill out Home Medication

Reconciliationform

EclipsysSCC?

YES

No

Place form intochart behind

Med Administration tab

Admission

Transfer Discharge

Admission

Transfer Discharge

Admission

Transfer Discharge

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Admission

Transfer Discharge

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

Non-Eclipsysand

Non-POE

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

Non-Eclipsysand

Non-POE

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

No-Eclipsysand

No-POE

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Admission

Transfer Discharge

No-Eclipsysand

No-POE

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

Prescriber considers

“Home” Med List and

Meds used just prior to transfer

When developing transfer orders

No-Eclipsysand

No-POE

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

Prescriber considers

“Home” Med List and

Meds used just prior to transfer

When developing transfer orders

No-Eclipsysand

No-POE

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

Prescriber considers

“Home” Med List and

Meds used just prior to transfer

When developing transfer orders

No-Eclipsysand

No-POE

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

Place form intochart behind

Med Administration tab

Prescriber considers

“Home” Med List and

Meds used just prior to transfer

When developing transfer orders

No-Eclipsysand

No-POE

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

Place form intochart behind

Med Administration tab

Prescriber considers

“Home” Med List and

Meds used just prior to transfer

When developing transfer orders

No-Eclipsysand

No-POE

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

Place form intochart behind

Med Administration tab

Prescriber considers

“Home” Med List and

Meds used just prior to discharge

When developing discharge orders

No-Eclipsysand

No-POE

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Admission

Transfer Discharge

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Receiving Unit

Admission

Transfer Discharge

Place form intochart behind

Med Administration tab

Prescriber considers

“Home” Med List and

Meds used just prior to discharge

When developing discharge orders

No-Eclipsysand

No-POE

PrescriberSigns

Transfer Reconciliationform

Clerical Assoc. or Nurse sends patient specificpatient specific

Transfer Reconciliation form

Sending Unit

POEand/or

Eclipsys

Clerical Assoc. or Nurse sends non-patient specificnon-patient specificTransfer Reconciliation form

Receiving Unit

Medication ReconciliationMedication ReconciliationNext Steps Next Steps

Improve compliance with current Improve compliance with current systemsystem

Automate reconciliation processAutomate reconciliation process Improve reconciliation in outpatient Improve reconciliation in outpatient

sectorsector