IMM 20: MTM in HP II

Question 1

What is medication reconciliation?

Answer 1

formal process in which healthcare providers work together with patients to ensure accurate and comprehensive medication information is communicated consistently across transitions of care

• will inform an enable prescribers to make the most appropriate prescribing decisions for the patient
• requires BPMH to ensure that medications being added, changed, or discontinued are carefully evaluated

Question 2

What is a best possible medication history (BPMH)?

Answer 2

complete and accurate list of all the medications a patient is taking created using at least 2 sources of information including a client and/or family interview

• involves systematic process of interviewing patient/family
• involves review of at least one other reliable source of information – medication vials/list, government medication database, previous patient health records

Question 3

Describe some of the evidence supporting pharmacy involvement in Medication Reconciliation.

Answer 3

• pharmacy students improved accuracy of medication histories (67%)
• 98.5% of medication histories contained at least one medication discrepancy – less than 1% were found on the medication history conducted by pharmacy
• pharmacists identified adverse drug events in 35.6% of patients
• 96% discrepancies identified by student pharmacists

Question 4

What are the steps to BPMH?

Answer 4

1. gather information from various sources

• interview patient/caregiver
• at least one additional source – vials, blisterpacks/adherence aids, MARs, med calendars or med list, community pharmacy, Pharmanet

2. compare information
3. identify and resolve differences
4. document

Question 5

Describe the BPMH interview process.

Answer 5

1. opening

• introduction and purpose
• ask about how patient takes their meds
• ask where patient fills their meds

2. categories of meds

• prescribed
• non-prescription
• natural health products
• cannabis
• ask how many, what strength, how often, when, most recent dose, indication, changes

3. lifestyle

• non-medicinal substances – alcohol, cigarettes, caffeine
• might affect health and meds

4. allergies

• meds or foods
• environmental
• details about reaction
• details about challenges, tests, or trials

5. closing

• express thanks
• provide contact information
• address any questions

Question 6

What are the different parts of a medication history on an Admission MedRec form?

Answer 6

• collection – Pharmanet
• verification – how the patient is taking the medication, who it was verified with, last taken (ie. taking differently (specify), per Pharmanet, no longer taking, unable to verify)
• reconciliation – actual medication orders (ie. give as per verified history, give as per Pharmanet)
• interviewer date/time/signature/initials
• prescriber signature if discussed with MD/sign as verbal order