Podcast
Questions and Answers
Which option should be selected in the Medication Orders column for the esomeprazole order if the patient is not currently taking it?
Which option should be selected in the Medication Orders column for the esomeprazole order if the patient is not currently taking it?
What would be an appropriate entry in the 'Verified with' column for salbutamol if the patient specifies using it as needed?
What would be an appropriate entry in the 'Verified with' column for salbutamol if the patient specifies using it as needed?
If the verification indicates that a patient is taking salbutamol 1 puff 4 times a day, which option is correct for the Verified with column?
If the verification indicates that a patient is taking salbutamol 1 puff 4 times a day, which option is correct for the Verified with column?
What does selecting 'Per PharmaNet' imply in the context of a medication order?
What does selecting 'Per PharmaNet' imply in the context of a medication order?
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In the circumstance where medication intake cannot be verified, what option would be the most appropriate?
In the circumstance where medication intake cannot be verified, what option would be the most appropriate?
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What is the primary purpose of Medication Reconciliation in a hospital setting?
What is the primary purpose of Medication Reconciliation in a hospital setting?
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What does BMPH stand for in the context of Medication Reconciliation?
What does BMPH stand for in the context of Medication Reconciliation?
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Which of the following is NOT a component of the Admission Medication Reconciliation process?
Which of the following is NOT a component of the Admission Medication Reconciliation process?
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Which of the following best describes what is involved in the BPMH interview process?
Which of the following best describes what is involved in the BPMH interview process?
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Why is pharmacy involvement critical in the Medication Reconciliation process?
Why is pharmacy involvement critical in the Medication Reconciliation process?
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In the evidence supporting pharmacy involvement in Medication Reconciliation, what was a key finding from the study conducted between January and April 2007?
In the evidence supporting pharmacy involvement in Medication Reconciliation, what was a key finding from the study conducted between January and April 2007?
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What is one of the outcomes of proper Medication Reconciliation during transitions of care?
What is one of the outcomes of proper Medication Reconciliation during transitions of care?
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What key factor must be ensured before medications are added, changed, or discontinued during Medication Reconciliation?
What key factor must be ensured before medications are added, changed, or discontinued during Medication Reconciliation?
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What percentage of medication histories contained at least one medication discrepancy?
What percentage of medication histories contained at least one medication discrepancy?
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In the prospective study, what percentage of patients had adverse drug events identified by pharmacists?
In the prospective study, what percentage of patients had adverse drug events identified by pharmacists?
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What was the overall relative reduction in the number of days patients were admitted to the hospital when pharmacists led the medication review?
What was the overall relative reduction in the number of days patients were admitted to the hospital when pharmacists led the medication review?
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Which of the following was identified as a source for gathering medication information?
Which of the following was identified as a source for gathering medication information?
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What level of medication history discrepancies did student pharmacists identify?
What level of medication history discrepancies did student pharmacists identify?
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What was a notable finding regarding the control group in the student pharmacist study?
What was a notable finding regarding the control group in the student pharmacist study?
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What percentage of significant errors were categorized as serious or life-threatening?
What percentage of significant errors were categorized as serious or life-threatening?
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Which type of information should be reconciled with the BPMH process?
Which type of information should be reconciled with the BPMH process?
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During an interview for medication reconciliation, what should be verified about the medication vials?
During an interview for medication reconciliation, what should be verified about the medication vials?
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What practice is recommended to resolve discrepancies found in a patient's medication history?
What practice is recommended to resolve discrepancies found in a patient's medication history?
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Which criteria would NOT be a consideration when reviewing MARs?
Which criteria would NOT be a consideration when reviewing MARs?
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How many interventions did pharmacists make in the retrospective study?
How many interventions did pharmacists make in the retrospective study?
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What is an important factor when gathering information about a patient's own medication list?
What is an important factor when gathering information about a patient's own medication list?
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What intervention was done by pharmacy technicians in the retrospective chart review?
What intervention was done by pharmacy technicians in the retrospective chart review?
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Which medication was the patient switched to from ranitidine?
Which medication was the patient switched to from ranitidine?
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In the medication reconciliation order form, what action should be taken for ramipril if the patient’s history confirms it is the correct dosage?
In the medication reconciliation order form, what action should be taken for ramipril if the patient’s history confirms it is the correct dosage?
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What is the prescribed dosage of Vancomycin for Jerry Black?
What is the prescribed dosage of Vancomycin for Jerry Black?
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If a patient has decided to stop taking naproxen, what is the appropriate action on the medication order form?
If a patient has decided to stop taking naproxen, what is the appropriate action on the medication order form?
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Which option would you select to indicate a patient has stopped taking esomeprazole?
Which option would you select to indicate a patient has stopped taking esomeprazole?
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What information is needed to properly fill out the 'Verified with' column for medication reconciliation?
What information is needed to properly fill out the 'Verified with' column for medication reconciliation?
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Which column should be used to note changes to a medication order based on the patient's report?
Which column should be used to note changes to a medication order based on the patient's report?
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What should you do if the patient's history contradicts the medication listed in PharmaNet?
What should you do if the patient's history contradicts the medication listed in PharmaNet?
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What is the main purpose of completing a medication reconciliation order form?
What is the main purpose of completing a medication reconciliation order form?
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Which medication is indicated for treating osteomyelitis in the case provided?
Which medication is indicated for treating osteomyelitis in the case provided?
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If the patient is taking a multivitamin daily, how should this be recorded on the medication reconciliation form?
If the patient is taking a multivitamin daily, how should this be recorded on the medication reconciliation form?
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What is the appropriate action to take if a patient's medication history is unable to be verified?
What is the appropriate action to take if a patient's medication history is unable to be verified?
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When reconciling medications, what is the role of the clinical pharmacist?
When reconciling medications, what is the role of the clinical pharmacist?
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In the context of medication reconciliation, what does 'DTP' stand for?
In the context of medication reconciliation, what does 'DTP' stand for?
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Study Notes
Medication Reconciliation
- Medication reconciliation is a process of ensuring that a hospitalized patient's medications are correct and safe for their current condition.
- Medication reconciliation uses a Best Possible Medication History (BPMH).
- BPMH involves a systematic process to interview the patient/family and the review of other reliable sources of information.
- BPMH is performed at admission, transfer, and discharge.
- Medication reconciliation helps healthcare providers make better prescribing decisions.
Why Pharmacists Should Be Involved
- Pharmacists and students can play a crucial role in medication reconciliation.
- Studies have shown that pharmacists are more effective at identifying medication discrepancies than Registered Nurses (RN).
- Pharmacist involvement can lead to a reduction in hospital stay duration.
- Pharmacists can identify adverse drug events and help prevent medication errors.
The BPMH Interview Process
- Gather information from different sources.
- The patient/family/caregiver should be interviewed.
- Other sources like vials, blister packs/adherence aids, MARs, med calendars, community pharmacy, and Pharmanet should be consulted.
- Information from different sources should be compared and differences resolved.
- Information should be documented.
Resources for Information
- Medication vials: Check the date of the vial, the name on the vial, and whether the medication in the vial matches the label.
- Blister packs: Check for updates since the last pack.
- MARs: Different facilities have varying formats, be aware of the administration of doses, PRNs, doses held, and changes.
- Patient's own med list: Check the date, last updated, and who wrote the list. Ensure all medications are included, including over-the-counter medications.
Documentation
- Documentation is crucial when completing a medication reconciliation form.
- The medication history form should be completed with the date, time, interviewer's signature, and initials.
- If discussed with the physician, a prescriber signature is required.
Practice Case 1
- A 28-year-old male admitted for cellulitis was taking clindamycin 300 mg po QID for 5 days prior to admission.
- The ER MD started him on Cefazolin 1 g IV q8h.
- He was also taking omeprazole 20 mg po daily PRN for reflux, even though his Pharmanet showed a prescription for 20 mg po daily.
- The patient stated that he was taking ranitidine 150 mg po daily for reflux, but his Pharmanet showed a prescription for this medication.
- The patient was also taking a multivitamin tablet po daily.
Practice Case 2
- Jerry Black was admitted for osteomyelitis and the ER clinical pharmacist was asked to complete a med rec order form.
- The ER physician decided to start the patient on Vancomycin 1000 mg IV q8h x 8 weeks instead of cephalexin.
- The patient was already taking multiple medications before admission.
Practice Case 3
- Heather Knox, a 93-year-old female, was admitted for a hip fracture and the ER clinical pharmacist was asked to complete a med rec order form.
- She was taking ramipril 5mg po daily, naproxen EC 375mg po twice daily, esomeprazole 40 mg po daily, and salbutamol 2 puffs as needed.
- The patient stated that she was no longer taking esomeprazole and that she was only taking salbutamol 2 puffs as needed.
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Description
This quiz explores the process of medication reconciliation, focusing on the Best Possible Medication History (BPMH) and the importance of pharmacists in this critical healthcare process. Understand how medication reconciliation can enhance patient safety and improve prescribing decisions during patient admissions, transfers, and discharges.
