Initiatives

Review of overall process to complete reconciling

• Participants highlighted the importance of clearly differentiating the different steps in the process. At admission:
  
  1. Creating the home med list
     1. Assigning responsibility
        1. Someone with sufficient expertise
        2. Does not always have to be the same discipline (MD or RN or Pharmacist)
     2. Make the list as accurate as possible
        1. Don't let the perfect stand in the way of the "good"
        2. Don’t accept medication lists without questioning
     3. Understand it is a dynamic document, changing as more is learned from various sources
     4. Improving accuracy of home medication list
        1. Interview questions on back of form
        2. Bring in bottles
        3. Calls to pharmacy
  2. Make the list highly visible, easily available
     1. Colored paper
     2. Location of form
  3. Reconciling process
     1. Identify variances between home medication list and admission orders
     2. Setting time frames
        1. Time to next dose
        2. High-risk medications
        3. 24 hour maximum
     3. Document how variances are resolved
• Strong support for developing a high-level flow chart both of your current process and what the process will look like when you reconcile (examples are available in your binder, see pages 60 and 71; new flow chart examples were provided by UMass, Mercy). Offers best opportunity to build design that eliminates re-work, identifying ways to build reconciling process into nursing assessment, H&P, and medication ordering processes.

Assigning responsibility for creating the home list

• Safe practice recommendations note that this needs to be someone “with sufficient expertise”
• Many organizations have successfully introduced flexible arrangements: admitting RN or MD, whoever sees patients first (i.e. if MD goes to write orders, and no reconciling form completed, MD takes medication history, creates home med list on reconciling form, then writes orders). UMASS uses hospitalists, orthopedic residents, admission and PAT nurses, admission nurse practitioners.
• Organizations also use different strategies in different locations (Holyoke as RN on floor, RN/MD in ED)
• Using pharm techs identified as a cost-effective strategy (Fairview, Steve Meisel)
• Using case manager to create the home list (Lemuel Shattuck)
• Leveraging PAT, pre-admission assessments for planned admissions
• Leveraging wait time for ED patients scheduled for admission waiting for beds

Responsibility for completing reconciling

• RN with primary responsibility to ensure completion, contacting MD and passing off unreconciled meds at shift change
• MD must take ultimate responsibility for all orders. Must understand how home med list compiled/potential inaccuracies.
• Remain issues in resolving authority (surgeon vs PCP vs specialists)

Time frames for completing reconciling

The goal is to establish a policy that clearly identifies high-risk situations where resolution is required in a very short time, but avoids requiring calls to ordering prescribers in the middle of the night for non-urgent situations. Hospitals have adopted alternative specifications including both global time limits for all medications and strategies to vary time frame based on time of admission, medication risk. Some example strategies have included:

• Complete reconciling before next therapeutically prescribed dose
• Complete reconciling before morning rounds
• Reconciling process will be complete by 6 hours after admission (hospital set initial goal of achieving the 6 hour time frame for at least 50% of patients)
• Reconcile a specified set of high-risk medications w/in 4 hours of admission, others within 24 hours (see example time frame matrix)
• Key timeframe to time of next dose, with 24 hour maximum but target goal set for 6-8 hours with consideration of special circumstances for night admits and certain high-risk meds/circumstances needing reconciling within a short timeframe

It is important to avoid making this too complicated. In some tests of change, organizations found that splitting medications in two categories, while providing a rule that promotes consistent follow-up on variances that pose significant patient risk, forces the RN to take an extra step of looking up and matching each medication. With one reasonably short time frame, you can work with the goal of making a call to get all discrepancies reconciled at once.

Enhancing the reconciling form

Hospitals reported learning a lot from small tests of their draft reconciling forms. Many reported making a large number of minor enhancements (10, 32, etc.). Some examples of refinements:

• Renaming form to avoid confusion over what “reconciling” is:
  • “Medication Coordination Form” [BI]
  • “Preadmission Medication List Verification and Order Form” [UMASS]
  • Adding labels on half of the form as “Home Medication List” and the other half as “Verification” to clearly delineate the different steps in the process
• Strategies for clearly noting reconciling status:
  • Using codes such as R=reconciled, CA1=MD notified, CA2=dose change, CA3=discontinued, CA4=omitted med added)
  • Adding place for MD to check that they reviewed the med list
  • Adding signature line that notes that RN will be following up later when immediate MD contact is not required
• Add a column denoting “source of information” that will allow an assessment of the potential for inaccuracies; e.g. patient, family, prescription bottle, call to pharmacy, call to PCP/specialist, with potentially adding something a subset under patient to connote patient with potential cognitive/language barrier issues [Children’s Hospital’s form, for example, includes codes for parent report, prescription bottle/receipt, CDV, and Pharmnet]
• Redesign to add more space to write, especially comment line for each med (now can enter notes about how variances were reconciled, issues for discharge planning, etc.) [Emerson]
• Adding local pharmacy phone numbers
• Add a "*" after meds that would have a formulary interchange to alert MD of possible duplicate therapy after discharge
• Used as opportunity to educate re: unsafe/unacceptable abbreviations, adding list on the back [UMASS]
• Added “DRAFT” in big letters, along with a note saying “If this patient shows up on a floor other than 10North, just ignore this form”; very empowering in allaying concerns about patient going to units where education about reconciling had not yet been done [Children’s]
• Brought signature lines closer to the medication list after noticing that clinicians were forgetting to sign [UMASS]
• Adding context about compliance
  • Clarification right on the form as well as in staff ed materials that the home medication list should reflect the medications the patient is actually taking (not what’s prescribed)
  • Use of comments block to denote differences between dosages prescribed and actual usage
• Added column for “time of last dose”
• Revised options for MD order column to be more than just Y/N; now include “Yes: continue”, “No: discontinue”; and “Continue, with dosage change”
• Include a place on form to note if patient taking own med
• Add a section on the med form to emphasize importance of always including patient allergies, height, and weight
• Adding special column for short-stay patients: continue taking at home, drop route?

Holyoke Hospital Medication Reconciliation Form
Children’s Hospital Boston Pre-op home medication list
UMass Memorial Medical Center Preadmission Medication List Verification and Order Form
Cambridge Health Alliance Medication Reconciliation Form
Caritas Norwood Medication Reconciliation Form
Cooley Dickinson Hospital Pre-Admission Medication List Verification