TRANSITIONS IN LONG-TERM CARE: MEDICATION RECONCILIATION

Improper medication reconciliation leads to errors

One study found that

1 out of every 3 medication errors could be attributed to either a lack of knowledge about the medication or the patient

6 Common Mistakes

• Failure to restart medications (e.g., anticoagulants)
• Continuing medications that should have been stopped at discharge from the hospital (e.g., standing orders for sleep aids, electrolyte replacement protocols)
• The wrong drug or dose is recorded (e.g., Celebrex instead of Celexa, 15 mg vs. 50 mg)

6 Common Mistakes

• Duplication in therapy (e.g., a home medication and a hospital formulary medication for the same indication)
• Omission of a "home" medication or supplement (e.g., levothyroxine, calcium, estrogen)
• Omission of time related information (e.g., the last time a weekly dose was given, or a patch was applied)

PRACTICE THE 7 RIGHTS OF RECONCILIATION

• Right person
• Right drug
• Right dose
• Right route
• Right frequency and timing
• Right indication for use
• Right doumentation protocol

RIGHT PERSON

RIGHT MEDICATION

• Beware of look alike/sound alike medications
• Verify any unusual/unfamiliar medications
• Any doubt? Spell it out when receiving verbal orders

RIGHT DOSE

• Verify dose changes
• Clarify sound alike doses when taking verbal orders (e.g., 15 may sound like 50)
• Write the correct units for each order (e.g., mg, mEq)

RIGHT ROUTE
Has the route changed (e.g., IV to PO)?
Does the route make sense?

RIGHT FREQUENCY AND TIMING

• Make sure a frequency is recorded (e.g., daily)
• Record the last dose administered, especially with unusual frequencies (e.g., weekly on Wednesday)
• Clarify start and stop dates for certain medications (e.g., antibiotics, anticoagulants)

RIGHT FREQUENCY AND TIMING

• Clarify any orders that are on "hold", specify to discontinue, restart on a certain date, etc.

RIGHT INDICATION FOR USE

• All medications should have a specific, relevant indication (including prn orders)
• Clarify if certain indications are valid (e.g., electrolyte replacement, infections, reason for anticoagulation, unfamiliar indications)

RIGHT INDICATION FOR USE

• Ensure range orders have a dose or frequency specific reason for use (e.g., pain scale to determine when to use a low vs. a high dose of pain medication)

RIGHT DOCUMENTATION PROTOCOL

• Avoid error-prone abbreviations (e.g., MSO4)
• Avoid trailing zeros (e.g., 2.0 mg should be written as 2 mg)
• Always put a zero in front of a leading decimal (e.g., .5 mL should be written as 0.5 mL)

RIGHT DOCUMENTATION PROTOCOL

• Do not obliterate or overwrite errors. Instead, use a single line to cross out the error, date and initial, and re-write the order clearly
• Document that verbal orders were read back and include the prescriber's name, your name, the date and the time.

NEVER ACCEPT BLANKET ORDERS
(e.g., "continue same orders")

Practice the 3 "C" APPROACH

• Collect all relevant medication information
• Clarify discrepancies, or anything that is unclear, or unfamiliar
• Correct documentation processes should consistently be followed by all staff performing reconcilation

Care through your actions