MEDICATION RECONCILIATION

1.0 PURPOSE
1.1 Medication Reconciliation is the process of comparing patients medication orders to all of the medications that the patient has been taking. It is an interdisciplinary process between the Nursing, Medical Staff, and Pharmacy. This reconciliation is performed to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be performed at every transition of care in which new medications are ordered, or existing orders are rewritten. Transition in care includes changes in setting, service, practitioner, or level of care. 2.0 POLICY 2.1 All patients will have all medications reconciled upon admission. The final outcome of this process is to generate the most accurate medication list available. 2.2 The staff will enter the current medication including the name of the drug, frequency, date, and data source (pill bottle, referral meds, patient/family report) into prescription writer. The physician will complete the process via the medication reconciliation section in the nursing floor. 2.3 Each time patient moves from one setting to another, the medical staff should review previous medication orders alongside new orders and plans for care, and reconcile any differences.

3.0 PROCEDURE
3.1 Admission 3.1.1 The admitting nurse will obtain the most current list of medications the patient is currently taking (Active Medications). The medication history must include prescribed medications, herbal or dietary supplements, including dosage, frequencies, and routes of administrations. (Form patients med receipts). If the patient is not a reliable source or information is questionable, the nurse will make effort to clarify information or seek additional data.

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The patients medications are placed in a box located in nursing units for patient who are admitted directly to the units. The pharmacist will verify the received medications upon the order of the prescribing physician. (Except for Outpatient services wherein medications brought in by patient will be sent back home). It is the responsibility of the physician to reconcile the medication list and the physicians admission orders.

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For discontinued medications, the nurse will write the date the medication was discontinued in the medication reconciliation form.

3.2 Consultation / Room Transfer 3.2.1 Upon transferring of patient to another ward, the nursing staff shall endorse the medication reconciliation form to the next service provider/nursing unit. The receiving physician reviews the consultation notes/recommendations for inclusion in the treatment orders as appropriate. Rationale for any changes in medications shall be recorded in the progress notes.

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3.3 Discharge Procedure 3.3.1 The physician discharging the patient must reconcile the discharge prescriptions with the initial medication history on the medication reconciliation form. The physician will decide what medication the patient will continue to take upon discharge.

3.3.2

3.3.3

The physician shall provide written prescription of medication to patients upon discharge. The nurse shall ensure that the written prescription is the same as what is written in the home instruction.

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3.3.5

The pharmacist compares discharge orders to active orders and discharge notes including home medications at the time of discharge and notifies the attending physician for any discrepancies.