Medication Reconciliation: Bridging Communications Across the Continuum of Care

Legacy Health System's Medication Reconciliation Task Force created a process to reconcile our patients' medications in order to improve the safety of our patients and to meet the Joint Commission's National Patient Safety Goal #8: Accurately and completely reconcile medications across the continuum of care.

This research was supported by grant number 5U18HS015904-02 from the Agency for Healthcare Research and Quality (AHRQ). The contents of this product are solely the responsibility of Legacy Health System and do not necessarily represent the official view of or imply endorsement by AHRQ or the U.S. Department of Health and Human Services.

The project created a process to accurately reconcile a patient's home medications with the medications he/she receives in the hospital, plus any medication changes ordered at discharge. The patient leaves the hospital with a detailed list that explains what medications (old and new) he/she needs to take and, when appropriate, which medications he/she needs to stop taking. The patient's next provider of service also receives a copy of the patient's current medication list. This process reduces medication errors and improves patient safety by ensuring that the patient understands his/her medication regimen and that all caregivers across the continuum of care have accurate and up to date information.

Legacy Health System grants permission to other hospitals and healthcare systems to use the medication reconciliation process and collateral materials we have created, with credit to Legacy Health System.  If you have questions, please contact us .

Summary of the Interdisciplinary Responsibilities for Medication Reconciliation

Nursing

Nursing Responsibilities

1. Interview patient/family and collect home medication list on admission.
2. Contact family, retail pharmacy, primary care physician and/or skilled nursing facility if clarification is needed.
3. Print out patient's medication list from RxPad and place it in the patient's chart (nursing or unit secretary responsibility)
4. For transfers, print out RxPad medication list and optional Medication Admin Guide and place in chart (nursing or unit secretary responsibility)
5. Print out updated RxPad med list upon discharge (nursing or unit secretary responsibility)
6. Review medications with the patient/family members and give them the list
7. Fax the new home medication list to the next provider of service (nursing or unit secretary responsibility)

Nursing Training Materials/Collaterals (see also: Collateral Materials)

• Medication Reconciliation Training Packet for the Admitting Nurse  (PowerPoint format)
• Medication Reconciliation Training Packet for the Admitting Nurse  (PDF)
• Nursing Medication Reconciliation Process Steps (PDF)
• Nursing Medication Reconciliation Process Steps (Word format)
• RxPad Cheat Sheet (PDF)
• RxPad Cheat Sheet (Word format)
• Fax cover letter for pharmacies (PDF)
• Fax cover letter for pharmacies  (Word format)
• Fax cover letter for next provider   (PDF)
• Fax cover letter for next provider   (Word format)
• Flow Chart for Medication Reconciliation of a Direct Admit  (PDF)
• Flow Chart for Medication Reconciliation at Discharge  (PDF)
• Medication Reconciliation Audit for Inpatient Units  (PDF)
  

Pharmacy

Pharmacy Responsibilities

1. Enter RxPad home medications into the E-Chart inpatient profile as per the physician's admission and transfer orders.
2. Document "Medication Reconciliation Complete" in the E-Chart inpatient profile (this will show up on the nightly MAR) at admission & transfer.
3. Review & evaluate the patients’ lists of home medications for safety and efficacy and/or clarify incomplete information based upon nursing and provider requests.
4. Notify the physician about medication-related problems and recommendations, when applicable.
5. Assist nursing and medical staff with RxPad as needed.

Pharmacy Training Materials/Collaterals (see also: Collateral Materials )

• Pharmacist Self-Learning Module  (html) for medication reconciliation process

Physician

Physician Responsibilities

1. Admission: The admitting physician reviews the RxPad home medication list and orders medications as appropriate for inpatient use (this must be completed within 24 hours of admission).
2. Transfer: The receiving physician reviews the RxPad home medication list and orders home medications as appropriate for inpatient use.
3. Order discharge prescriptions in RxPad.
4. Print out and sign prescriptions to be given to the patient/family member, or electronically fax prescriptions to the retail pharmacy of patient’s choice (Schedule II prescriptions cannot be faxed).
5. Review and update the home medication list for discharge, discontinuing any medications from RxPad that the patient should not take after discharge.

Physician Training Materials/Collaterals (see also: Collateral Materials)

• Medication Reconciliation Instructions for Physicians  (PDF)
• Physician Instructions for RxPad Medication Entry and Faxing  (PDF)
• RxPad Cheat Sheet for Physicians (PDF)
• RxPad Cheat Sheet for Physicians (Word format)

Department-specific Materials/Collaterals

Emergency Department:

• Medication reconciliation in emergency departments  (PDF)
• Flow Chart for Medication Reconciliation in the Emergency Department  (PDF)

Outpatient Units:

• Medication Reconciliation Audit for Outpatient Units  (not using RxPad) (PDF)
• Medication Reconciliation Audit for Outpatient Units  (using RxPad) (PDF)

Last updated: 1/29/2008