Clinical Pharmacy Technician Medication Reconciliation within the VA

1. Clinical Pharmacy Technician Medication Reconciliation within the VA Kara Jackson Clinical Pharmacy Technician Minneapolis, MN

2. Medication Reconciliation Flow • Upon admission: patient/caregiver/etc. interviewed by pharmacy (technician or pharmacist) • Med Recon Note entered into CPRS listing how patient actually takes medications (versus Rx direction) • Physician uses Med Recon Note to order inpatient medications • Clinical pharmacist uses Med Recon Note to reconcile inpatient orders (versus home medications) • Identifies discrepancies or problems and clarifies with physician

3. 1. Patient Roster • Assignment of PATIENTS to their corresponding Clinical pharmacists & by Medical team affiliation • Vista: inpatient roster report to file • Import into Excel® via text import wizard • Excel®: able to sort by ward, patient name, RPh, medical team, etc…

4. Roster – Technician responsibilities (cont) • Supply clinical pharmacists w/daily staffing schedule • Identify patient “name alerts” • Identify drugs that require special monitoring • gentamicin, tobramycin, vancomycin, enoxaparin, warfarin, heparin, argatroban, phytonadione tab, phytonadione inj • Provide copies to Pharmacy staff • Maintain current medical resident/team assignments • Residents rotate x2 monthly (teaching hospital)

5. Daily Roster: Example

6. 2. Interviewing/Obtaining Medication History (Medicine Admits) • After daily Rosters completed, 1st order of day is to interview patients admitted overnight • “Holdovers” = overnight admissions • typically not interviewed by pharmacy yet • Work with clinical pharmacists to get all “Holdover” interviews completed

7. 2. Interviewing/Obtaining Medication History - Medicine Admits (cont) • New Admissions throughout the day • VISTA report (L24): real time notification of admits • Clinical technician monitors through the day • Will assist clinical pharmacists with interviews if needed/available • Emergency Room: check in to ER @ 1000, 1200, 1400 • Communicate with ER Physicians – who are they admitting to hospital? • Communicate with ER Pharmacist • Communicate admits to clinical pharmacists • Enter Med Recon Note in CPRS • Update “MEDICINE Med Recon List” which department uses as a communication tool (Excel® spreadsheet)

8. Medicine Med Recon List

9. 3. Surgery Med Recon • Anticipate all Surgical patients who will be admitted to hospital (post-op) • Vista: search by appointment title and other sources • Add patients to : “SURGERY Med Recon List” • utilized as a communication tool (Excel® spreadsheet) • Begin calling patients 3-4 day prior to surgery • Enter Med Recon Note in CPRS • include pre-op medication instructions • MD added as additional signer on day of surgery

10. Schedule of Operations • @ 1430 daily: Surgical Service sends copy of “Schedule of Operations” for the following day • Check schedule for last minute surgical add-on’s • Anticipated admits listed with post-op disposition: WARD &/or 2LOBS • Add names to “SURGERY Med Recon List” • Set up document(s) & call patient • Communicate to Access Clinic technician

11. Access Clinic Technicians • Technicians available as “back-up” • Available to make phone calls/interview 2KOBS patients after 1530 • Communicate evening duties via “SURGERY Med Recon List” &/or verbal instruction • Provide coverage in [my] absence (SURGERY Med Recon ONLY) • (trial): assist evening AD with Medicine admits

12. In Conclusion: • Summary of Responsibilities: • Organize and maintain Roster(s): assign pharmacists to their patients (by team & MD) • Organize communication tools • Roster(s), Med Recon Lists(s), L24 • Interview Medicine admits • Interview Surgery admits • Anticipate admits, set up documents, & call 3-4 days in advance • Provide guidance to Access Clinic technicians