Reconciling the Differences. Karen Lippett B.Sc.Phm Humber River Regional Hospital Renal Dialysis Unit

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1 Reconciling the Differences Karen Lippett B.Sc.Phm Humber River Regional Hospital Renal Dialysis Unit

2 Objectives 1. Review the medication discharge counselling process in the renal dialysis program 2. Illustrate how medication reconciliation decreases adverse drug events 3. Potential future improvements

3 HRRH Outpatient Dialysis Unit: Patient Population Pre-Dialysis Unit 510 Incenter Hemodialysis 276 (on line) Home Hemodialysis 86 (on line) Peritoneal Dialysis 40 (on line) Average # Meds per Patient = 10 to 15

4 Out In Out Cycle Renal Dialysis Program primarily an outpatient service but.. Outpatient ~ Inpatient ~ Outpatient (400) (Average 20) (400) Requires seamless flow of medication related information

5 Background Work by Pharmacist (in Outpatient Dialysis Unit) Medication history Computerized medication record Continuous medication record update in computer as new outpatient orders written Six month medication review

6

7 Inpatient Dialysis Patient Upon admission, medication history readily available in hospital computer system Nephrologist writes admission medication orders based on this record Renal pharmacist reconciles admission orders with computer med history Discrepancies clarified with nephrologist

8 Goals of the Renal Medication Discharge Program To ensure patients/families/community pharmacists/nursing homes receive all the necessary prescriptions and medication information To ensure seamless transfer of medication information from inpatient services to outpatient services To provide accurate computerized medication profiles

9 RENAL DISCHARGE SUMMARY REASON FOR ADMISSION: POST-DISCHARGE CLINIC/DIALYSIS APPOINTMENTS: FOLLOW-UP ISSUES: NOTIFY FOLLOWING PERSONNEL ABOUT DISCHARGE: RENAL PHARMACIST SOCIAL WORKER HOME CARE RENAL DIETITIAN OTHER: DISCHARGE MEDICATIONS TO BE CONTINUED IN DIALYSIS UNIT Erythropoietin Venofer Danaparoid Antibiotics (specify) start of hemodialysis Line-locking: Heparin 10,000 U/mL solution Anticoagulant Citrate Dextrose solution (ACD) Other: t e a r a l o n g t h e p e r f o r a t i o n DISCHARGE MEDICATIONS: Name: Address: 200 Church Street Toronto, ON M9N 1N8 (416) Physician's Signature: Date: Print Name: Repeat times (01/02) WHITE - patient copy YELLOW - Dialysis Unit PINK - Pharmacy ORANGE - Chart

10 Renal Discharge Summary Form Form consists of the original plus 3 copies ORIGINAL given to patient with written instruction for follow-up & prescription for community pharmacist FIRST COPY forwarded to renal pharmacist SECOND COPY forwarded to renal dialysis unit (copy put in outpatient chart with summary of active medication orders) THIRD COPY remains on inpatient chart as a permanent discharge record

11 Role of Renal Pharmacist 1. Reconcile medications on RENAL DISCHARGE SUMMARY form with (a) inpatient record AND (b) pre-admission renal dialysis outpatient record 2. Contact nephrologist to clarify discrepancies 3. Update the on-line medication record and generate a computerized medication calendar for patient

12 Role of Renal Pharmacist 4. Contact patient to review medication CHANGES and provide medication counselling 5. Follow up with community pharmacist and/or nursing home to ensure medication regimen is updated 6. Pharmacist documents on line discharge summary note

13 Medication Related Problems at Discharge 1. Discrepancies with discharge Rx: -change in dose -new medication ordered -omission of regularly prescribed med -inappropriate time of administration -duplication of therapy -auto-sub in hospital -hold medications

14 Discharge Problems cont d 2. Patient Related: -Rx not filled -High cost meds not purchased (need LU code or Section 8) -OTC not purchased -Nursing Homes; - Discharge Summary not received - Covering MD changes orders

15 How are medication discrepancies resolved? MEDICATION RECONCILIATION by the Renal Pharmacist

16 Renal Inpatient Discharge Medication Program - Outcome Pharmacist driven program implemented 2001 No baseline data with respect to medication reconciliation and frequency of discrepancies % Patients Counselled by Pharmacist on Discharge: Prior to program start up 20% 3 months post start up 71% 4 years post start up 80%

17 Problems Identified With Renal Medication Discharge Program: 1. Legibility of doctor s handwriting on discharge form 2. Poor readability of 4 th carbon copy of discharge form 3. Discharge form not received by key players 4. Undocumented intentional discrepancies by nephrologist

18 Possible Solutions 1. Physician Discharge Prescription Software in hospital computer system -computer generated prescription (elimination of illegible med orders) 2. Educate nephrologists re documentation of intentional discrepancies

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