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Medication Reconciliation

Pharmacy Orientation

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Outline

Review on completing Best Possible Medication Histories (BPMHs) and medication reconciliations (MedRecs)

Overview on how BPMHs and MedRecs are implemented within Epic/Connect Care

Highlighting downstream problems that occur when done incorrectly

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We’ll start by defining a Best Possible Medication History (BPMH) as a history created using 1) a systematic process of interviewing the patient/family; and 2) a review of at least one other reliable source of information to obtain and verify all of a patient's medication use (prescribed and non-prescribed).

Complete documentation includes drug name, dosage, route and frequency.

Medication reconciliation is a formal process which follows the BPMH, whereby medications being added, changed or discontinued are carefully evaluated.

It is a component of medication management and will inform and enable prescribers to make the most appropriate prescribing decisions for the patient.

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This presentation will focus on completing BPMHs with patients and documenting this process within Epic.

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Who Completes the BPMH?

Pharmacists are particularly adept with medication management, and when able:

Will see patients to complete their BPMHs

Typically done in a retroactive fashion
Will document any discrepancies and resolve them with the team

BPMHs are a multidisciplinary task, which can be completed by different members of the care team.

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What a BPMH Is Not

Primary Medication History	BPMH
Created ad hoc to quickly list a patient’s medications (i.e. at triage)	Created through a thorough, systematic process (i.e. on admission)
Uses a single source of information (i.e. patient interview; Netcare PIN)	Relies on a patient interview plus secondary sources as collateral

Overall, a BPMH is a complete and accurate list of medications that reflects medication use prior to admission which can be used to safely create (and later re-assess) medication orders.

Adapted from Canadian Patient Safety Institute/ISMP Canada Medication Reconciliation in Acute Care Getting Started Kit (Version 4)

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Steps to complete a BPMH

From Canadian Patient Safety Institute/ISMP Canada Medication Reconciliation in Acute Care Getting Started Kit (Version 4)

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Secondary Sources of Information

Netcare medication history
Facility MARs (if from a site not on Connect Care)

Look for green sleeve or in “Media”

Blister packs, compliance labels or medication vials

“Are you taking anything outside of your blister pack?”

Previous hospital records or discharge summary
Community pharmacy

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In preparing to interview patients, reviewing secondary sources of information is key. Some of these include:

- The Netcare medication history, which we will go over on the next slides.

Facility MARs – if a patient is coming from a long-term care facility, Netcare is often inaccurate. It is better to look for a patient’s green sleeve, which should elucidate the patient’s medications prior to admission. MARs may also be uploaded onto the media section of Connect Care.

- Blister packs – home care or assisted living patients, or patients with complicated medication regimes, often have blister packs for pills

REMEMBER to ask patients if they are taking anything outside of the blister pack – for example, PRN diuretics, warfarin, insulin, OTCs, inhalers and topical medications.

Discharge summaries – use discharge meds with caution. Look for WHEN the patient was discharged. If its been a few weeks, those meds can often be inaccurate.
And finally you can always call the community pharmacy

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Practical Netcare Tips

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Pitfalls of Netcare

The medication profile only indicates that medications were filled by a community pharmacy – not that they were picked up by the patient

And if they were picked up, the Netcare profile cannot explain how the patient is actually taking the medication

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Pitfalls of Netcare

Fills may be delayed or absent altogether

Due to technical delays with pharmacies uploading to Netcare
Due to the patient’s PHN being incorrect on the community pharmacy’s software

Fills may be incorrect altogether

Due to the pharmacy filling medication under the wrong patient profile

Missing from Netcare: out-of-province fills, medications given in-hospital or prison, physician samples

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Pitfalls of Netcare

Consider the Netcare history as a suggestion of what the patient may be taking.

** Ultimately, medications must be confirmed with the patient or caregiver. **

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Specific Questions to ask Patients

Do you have your medications with you?

Are they in vials or in a blisterpack?

For each medication:

How do you take it? How often or when do you take it? How much do you take?

Focus on the dose, route and frequency

Were there any recent changes made to your medications?

Have you recently increased or decreased any of your doses?
Have you stopped or started any new meds?

If so, why?

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After working up a patient, we would then interview them. Some specific questions to ask include:��Do you have your medications with you?

Are they in vials or in a blisterpack?��From here, patients can be asked about each medication on their person.

We can ask questions such as:

How do you take it? How often or when do you take it? How much do you take? We want to focus on the dose, route and frequency. These questions are especially important for medications that require constant adjustment, such as warfarin or insulin.

Were there any recent changes made to your meds?

Have you recently increased or decreased any of your doses? Perhaps the patient’s family doctor verbally asked them to change how they take their medications without issuing a new prescription – this would not be noted on Netcare.
Have you stopped or started any new meds?

If so, why?

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Specific Questions to ask Patients

Do you take any medications that you buy without a doctor’s prescription?

Do you take any vitamins/minerals/supplements?

Are you taking any samples from your doctor?

Do you use any medications that aren’t pills?

i.e inhalers, eye/ear drops, nasal sprays, patches, liquids, injections, ointments/creams

In a typical week, how often do you take (or forget to take) your medications?

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Completing a BPMH and Medication Reconciliation within Epic

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Getting Started

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Getting Started

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Inputting Home Meds

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Adding Notes

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Adding Notes

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Time of Last Dose

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Using the Database

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Using the Database

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Adding “OTHER” meds

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Adding “OTHER” meds

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Inputting a Pharmacy

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Wrapping Up

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Wrapping Up

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Wrapping Up

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Mark As Reviewed

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Time to Reconcile!

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Reconcile Home Meds

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“Order”

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“Replace”

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“Replace”

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Ordering – Patient’s Own

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Ordering – Patient’s Own

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Ordering – Patient’s Own

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“Don’t Order”

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“Don’t Order”

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“Order and Hold”

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“Order and Hold”

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“Order and Hold”

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“Remove”

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“Remove”

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Discharge Reconciliation

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Practical Tips for Medication Reconciliation

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Pre-populated medications

Outpatient prescription

Patient-reported medication

Long-term medication

Clinic-administered medication

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Patients from LTC on Connect Care

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Common Mistakes with Admission Orders

Watch for duplicates

Eg. Emerge doc has ordered 1x dose of antibiotics or diuretics

Pay attention to start times of medications

Eg. Did the patient already take their dose at home?
Eg. Medications ordered weekly, monthly or q6months

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Amazing!�Now you know how to do MedRec!

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