How hospital's pharmacist admissions medication history program works

Pharmacists assist throughout hospital stay

One direct way to improve hospital medication safety is to have pharmacists involved in taking medication histories at admission and medication reconciliation from admission to discharge, one hospital has learned.

Froedtert Hospital in Milwaukee, WI, has improved its medication reconciliation process, enhanced patient care, and reduced medication errors and unintended discrepancies by having hospital pharmacists work with patients from the beginning.

Here's how the hospital's program works:

• Meet with patients soon after admission: "Pharmacists see patients who were admitted to the hospital within 24 hours of admission," says Kristin Hanson, MS, RPh, medication safety officer at Froedtert Hospital in Milwaukee, WI.

The hospital has an alert system that let's staff know about new admissions, says Carolyn Oxencis, PharmD, clinical pharmacist at Froedtert Hospital.

Pharmacists will meet with the new patients as soon as it's feasible, but first will do some preliminary work to see whether the patient has been admitted previously, Oxencis says.

If patients are unable to talk about their medications, then pharmacists meet with their family members, she adds.

The first step is to enter the room and double-check the patient's identification by verifying the patient's name and date of birth, she explains.

Oxencis introduces herself by her first name and explains that she's a pharmacist on that unit, and that she's there to ask about their medications.

"I say, 'We want to make sure physicians are aware of everything you've been taking; we're an important check to prevent mistakes,'" Oxencis says.

• Use detective skills to obtain complete medication list: By the time pharmacists meet new patients, a resident typically has already conducted a preliminary medication history and written orders, Hanson notes.

"But pharmacists do a much more extensive medication history, and they explain to patients what they're doing," she says.

For some patients, this interview process is straight forward, but for others it will take longer than 20 minutes to complete, Hanson adds.

Pharmacists ask patients about all of their prescription or over-the-counter (OTC) medications, including dietary supplements.

They'll ask about herbal teas, which some oncology patients take to help with the fatigue, or fish oil, which patients sometimes take for their cardiovascular health, or brewers yeast for cholesterol, Oxencis says.

"Sometimes patients are on more OTC supplements than medications," she adds.

"We talk about drug allergies and make sure our information is up to date about any allergies they might have," Oxencis says. "We talk about immunizations for flu, pneumonia, and hepatitis, and we ask where they pick up their medications."

Pharmacists also might ask patients who their community physician is so they can call the doctor's office for more medication information.

Or if a patient seems uncertain about a medication, the pharmacist might call the patient's pharmacy to check on which prescriptions the patient has and which have been recently filled, Oxencis says.

• Compile information for medication reconciliation:Pharmacists watch for drug omissions, incorrect names, wrong doses, and other potential problems.

"I put the medication list into computer systems, and then reconciliation begins," Oxencis says.

The information collected is put into the hospital's electronic medical record (EMR), which can then be compared to what the physician has put into the record.

"This is what pharmacists are trained to do," Oxencis says. "We learn patient interviewing skills, and we know the names of all medications, generic brands, how they're dosed," Oxencis explains. "So we get the best and the most accurate medication lists."

The EMR has a system for alerting staff to any major drug interactions. But there's also room in the electronic record for the pharmacist to note how reliable the list is.

"Sometimes the medication list is very reliable; sometimes it's not," Oxencis says. "Sometimes the patient lives alone, and sometimes we put a notation in our notes so doctors and nurses can see that this patient is really reliable, and we're really confident that they're taking these medications."

Pharmacists compare the physician's list to their own list and follow-up on any discrepancies they discover.

"We have to think about what we'll do about it and how significant it is," Oxencis explains. "Do I need to page the physician right away because this could be dangerous, or does the patient take a stool softener at home and would like to take one here, but I don't need to page the physician right away."

The hospital's policies and procedures provide guidance for how to deal with high alert medications or missed doses.

"Ideally, we want to reconcile everything within 24 hours of admission," Oxencis says. "Depending on the time, sometimes the day shift or the night shift pharmacist will take care of it."

• Follow-up with patients through discharge:Froedtert Hospital pharmacists stay involved with patient care throughout the patient's hospital stay, Hanson says.

"Pharmacists review all orders," she explains. "If there are any transfers, the pharmacist also is involved in reconciling those orders at transfer."

Also, pharmacists review medication orders for pre-operative and post-operative care, and they make recommendations throughout the hospitalization process, she adds.

Pharmacists do not provide medication reconciliation for every patient at discharge, primarily because the admission medication information and electronic EMR make this unnecessary.

"Most of the time, physicians and nurses can do the discharge part," Hanson says. "But we're continuing to look at opportunities for pharmacists and seeing what additional value a pharmacist could provide patients."