[medsurgnurse]

So now we are mind-readers? I mean nursing knowldge will help you figure out why a medicine was d/c'd. But how do we know what the physician's rationale is unless the physician WRITES IT OUT ON THE DISCHARGE SHEET.

[NRSKarenRN]

JCAHO Sentinel Alert

Issue 35 - January 25, 2006


Using medication reconciliation to prevent errors
Medication reconciliation is the process of comparing a patients medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Accurate and complete medication reconciliation can prevent numerous prescribing and administration errors.

Assign responsibility for comparing admission orders to the home medication list, identifying discrepancies, and reconciling variances to someone with sufficient expertise. ....

Creating a process for reconciling medications at all interfaces of care (admission, transfer, discharge) and determining reasonable time frames for reconciling medications. Patients, and responsible physicians, nurses and pharmacists should be involved in the medication reconciliation process.

--

ISMP Medication Safety Alert, April 21, 2005, http://www.ismp.org/MSAarticles/20050421.htm

...we have outlined the steps we suggest for implementing this process.

Obtain a medication history. Obtain the most accurate list possible of the patient's current medications upon admission to the organization before administering the first dose of medications (except in emergency or urgent situations). This includes prescription and over-the-counter medications (including herbals and dietary supplements), listing the dose, route, frequency, indication, and time of last dose. Most organizations use a specific form for this purpose, on which an assessment of patient compliance with drug therapy and the source of the medication history information can also be documented. Besides the patient and family, other sources of information may include visual inspection of the medications brought into the facility by the patient or family, previous medical records, as well as the patient's pharmacy and physician office.

Prescribe medications. As soon as the list is reasonably complete, have the prescriber review and act upon each medication on the list while prescribing the patient's admission medications.

Reconcile and resolve discrepancies. Require another person to compare the prescribed admission medications to those on the medication history list and resolve any discrepancies.

Reconcile again upon transfer and discharge. Each time a patient moves from one setting to another, review previous medication orders alongside new orders and plans for care, and resolve any discrepancies. When the patient is discharged, the reconciled list of admission medications must be compared against the physician's discharge orders along with the most recent medication administration record. Any differences must be fully reconciled before discharge.

Share the list. Communicate a complete list of the patient's medications to the next provider of service when transferring a patient to another setting, service, practitioner, or level of care within or outside the organization. This includes sending a list of medications prescribed upon discharge from the hospital to the patient's primary care physician, as well as encouraging patients to share the list with their pharmacy.

The Joint Commission requires hospitals to initiate this type of medication reconciliation process now. Full compliance is expected by January 2006.

Share the list---- only 2 out of SIX healthy system facilities share this list with my homecare agency despite this being 2006 safety goal.

Last night was trying to set up homecare at 6:30 PM from doctors faxed RX with patient name only; no DOB, address or phone number. Saw similar name in my computer data base, called patient and he confirmed had requested RX from this doc as LLE wounds reoccurred. That's typical of the type of referral my homecare agency receives. Try and get med list from PCP's nearly impossible!

20% homecare patients discharged from facilities without any medication RX too. HUGE issue that mushroomed as average homecare patient takes EIGHT RX medications when we've done chart audits.

[sassafrazzled]

The facility where I work just finished our JHACO jurvey and the reviewer said we were the first facility she had been happy with the reconciliation process. We are a rehabilitation facility and receive the majority of our patients from acute settings. On admission, we interview the patient regarding any/all meds they were taking at home and compare them to the list of meds we get from the transferring facility. Both lists are reviewed by the pharmacist for comparison... and discusses any differences with the physician. Most discrepancies between the two lists are due to 1. formulary changes (example: a patient takes nexium at home and the hospital uses protonix); 2. dose changes due to changes in the patient's condition; or 3. a med is being held (like asa before surgery). If the patient is started on a new med while in our facility, the pharmacy puts a sticker on the MAR to alert the nurse and the nurse checks a box to indicate whether or not the patient had any adverse reactions to that med. On discharge, the pharmacy prints a list of all currently ordered meds and the physician marks the list if he wants to discontinue any when the gets home. Nowhere in the process is it appropriate for the nursing staff to rationalize any of the above changes. We are obviously an integral part of the information gathering, and we educate the patient regarding any changes. I will have to follow up and see if the doc mantions any of this in the progress notes....

[gonzo1]

When patient is triaged in our ED or comes in by ambulance we list all meds being taken on the reconciliation form along with dose and frequency. Sometimes we are able to do this right away and sometimes it is done as a last thought before patient goes to the floor. It was hard getting used to doing this but it does make sense. It is important to be familiar with all the meds a patient is on and this was often glossed over in the past in our ER. Unfortunately, a lot of patients do not know what they take or why. Then we mark the "unable to reconcile" box. I note the drug, the dose and frequency, but rarely do more. Often we do not speak to the patients attending while they are in our ER and so are not able to discuss the meds with the attending. This is left for the floor nurse to do. Once in a while I do have the chance to talk to the attending and then I ask if they want each med continued, never do I get the chance to ask the doc why they are on each drug. These reconciliation forms are new and it will take time to work all the "bugs" out of the process.

[barbyann]

I am in the same mess as SEObowhntr. We are expected to "come up" with a rationale on the med recon. sheet. How the heck should I know what the doc was thinking? It is a great idea in theory but since most of my pts are frail elderly I tend to get responses like "I take one blue pill in the morning and two white ones at night" and "I forget the names". I write these exact words down on the med recon. sheet. I refuse to write why a med was not ordered. I am not a mind reader and the doc doesn't share with me. The med recon. sheet is filled out by the nurse at discharge. It is a disaster. Routinely the docs write discharge meds on the discharge form but they only include the new ones ordered. Then the nurses are stuck writing the med recon. d/c sheet. Are we to assume that the doc wants the pt. to resume all previous meds? If the pt. was on an antibiotic prior to admission, is it to continue? Then when you call the doc they get annoyed. I think this is best handled by putting the med recon. d/c sheet in the pts room and to let the pt. discuss their meds with the doctor. Use it as a worksheet of sorts. Better yet let the whole damn thing be the MD responsibility. Fight the fight SEObowhntr and keep us posted.

[rnmi2004]

We've been doing the med recon process the last few months, and it is driving us crazy. It falls on the nurses to "make it happen." O.K., sure, but last I checked we can't order meds & we can't force the docs to cooperate. It is like pulling teeth to get them to circle the "C" or the "DC."

Or how about the med recon sheets "filled out" by the office RN prior to a scheduled operation that the surgeon signs off on and what do you see? "Inhaler daily." "Ativan prn." Yes, I'm sure pharmacy is going to really like those orders. And when you do get specifics, the surgeon just ignores any attempts to get him to write a clarification order. Grrr...

I get why we're doing this--it is a great idea in theory--but it is a big hassle because so many of the MDs just aren't on board.

[king of codes]

The MD's have been clearly inept at ensuring a full medication regimine upon discharge, hence the needed JCAHO regs. Now, it becomes a nursing issue to do the MD's job, because heaven forbid the primary Doc be held accountable, when you have a nurse that will simply gripe and fill out the "newest" form.

Hospitals have put this upon nursing because we continue to pick up the slack and make every issue our own to solve that involves "OUR patient". They do it because they can, because we just do.... we can be such an enabeling profession....

I agree with you, these dang med rec sheets have broken my last nerve.... instead of writing ME up for not filling it out..... how about SUSPENDING PHYSICIAN PRIVELEGES until they become compliant! Wait!!!! no, the doc's all group together, act cohesively and buck the system together.... therein lies the difference.

I couldn' t get my group of nurses to fight this if their licenses depended upon it.... amazingly their licenses do. I've added document babysitter to my 10 page job description. Now if only I can find a way to justify calling the docs up at 2am to review these meds

I agree that this is NEEDED, it just doesn't need a nurse to occur.

[Beary-nice]

At the facility I work at it is the nurse's responsibility to gather all of the info about the meds, it is the doctor's responsibility to circle yes for continue and no for don't continue. It is also the doctor's responsibility to provide rationale about why they are ordering for a med to be discontinued. We are still getting used to it. UGH!

[SEOBowhntr]

Originally Posted by king of codes

The MD's have been clearly inept at ensuring a full medication regimine upon discharge, hence the needed JCAHO regs. Now, it becomes a nursing issue to do the MD's job, because heaven forbid the primary Doc be held accountable, when you have a nurse that will simply gripe and fill out the "newest" form.

Hospitals have put this upon nursing because we continue to pick up the slack and make every issue our own to solve that involves "OUR patient". They do it because they can, because we just do.... we can be such an enabeling profession....

I agree with you, these dang med rec sheets have broken my last nerve.... instead of writing ME up for not filling it out..... how about SUSPENDING PHYSICIAN PRIVELEGES until they become compliant! Wait!!!! no, the doc's all group together, act cohesively and buck the system together.... therein lies the difference.

I couldn' t get my group of nurses to fight this if their licenses depended upon it.... amazingly their licenses do. I've added document babysitter to my 10 page job description. Now if only I can find a way to justify calling the docs up at 2am to review these meds

I agree that this is NEEDED, it just doesn't need a nurse to occur.

Ain't that the truth. Nursing is so filled with passive, oh, I'll do whatever they tell me ignorant people that nurses can NEVER depend on each other for support. Forums like this could help, but I think it really is an older female ingrained thing. Not being sexist, but how often in and argument does a woman fold and just shut up to save a little face and keep peace, even if she doesn't get what she wants.

Our administration slid this through on all of the Med-Surg, OB, Psych, and Tele units first, then brought it to us in Critical Care and Step-Down, and told us everyone else is doing it and being compliant, so we need to to. And we said, "That is a PHYSICIAN RESPONSIBILITY, not a NURSE's."

[Zee_RN]

One of my biggest beefs about the nursing profession is that hidden duty: policing of physicians.

Our hospital has also instituted the Medication Reconcilation process. The Medication Reconciliation document is generated from the Admission Database and becomes an order form. The admitting nurse reviews and circles if a home medication was already ordered (say, in the Emergency Dept's orders). The admitting nurse is to call the physician within 4 hours of admission (or if she knows he/she is coming in within that time frame, the doc can fill it out) and ask which of these meds are to be continued or discontinued, and circle the appropriately. We are not required to provide a rationale.

On a side note, we are no longer allowed to use the words ANXIETY or AGITATION on any medication order. Period. If a person takes ativan at home and it is reordered prn, the reason is "...as per home medication." If they are attempting to rip out their endotracheal tube q15mins and you have an order for ativan, it must specifically state that in your order..."Ativan 2 mg IV prn for threats to endotracheal tube stability." *sigh*