Medication reconciliation

(adverse drug events: ADEs)

(potential adverse drug events: potential

ADEs) 6.5 5.5 100
1900 ADEs
1600 potential ADEs

56
34 6
4

(medication discrepancy)

54

47
39


60
250

4-6
(medication
delivery)
(medication management and use:

)

ADEs
Potential ADEs

ADEs

Potential Adverse Drug Events

Potential ADEs

(Walsh KE. )

Potential Adverse Drug Events

Potential ADEs : a serious medication error
one that has the potential to cause an
adverse drug event, but did not, either by
luck or because it was intercepted and
corrected.
Examining pADEs helps to identify both where the
system is failing (the error) and where it is working
(the interception). (Leape, 1998, Marimoto 2004)

Potential Adverse Drug Events

Synonyms: near miss, close call
An event or situation that could have
resulted in an adverse event but did
not, either by chance or through timely
intervention. (Aspden, 2004)



An act of commission or omission that could
have harmed the patient, but did not so as a
result of chance (e.g., the patient received a

Near miss

contraindicated drug, but did not experienced an

adverse drug reaction), prevention (e.g., a
potentially lethal overdose was prescribed, but a nurse
identified the error before administering the
medication), or mitigation (e.g., a lethal overdose
was administered but discovered early, and countered
with an antidote). (Aspden, 2004)



A near miss is any process variation
which did not affect the outcome, but
for which a recurrence carries a
significant chance of a serious adverse
outcome.
The Joint Commission states that these
near miss are within the scope of the
definition of a sentinel event.

(Coe CP., Uselton JP. Preparing the Pharmacy:Continuous

compliance with Joint Commission Standards. 6th ed. ASHP 2005)



Sometimes errors result in no serious harm
but are significant enough to be considered a
near miss. For example, a drug dosage is
administered to a patient via the incorrect
route, such as intravenously rather than
orally. The patient feels the effect, but
survives and suffers no permanent harm

Near miss

(Joint Commission. Root Cause Analysis in health care: tools and

techniques. USA:JCAHO, 2000)

Sentinel Events ()
Sentinel event is an unexpected occurrence
involving death or serious physical or
psychological injury, or the risk thereof.
Serious injury specifically includes loss of
limb or function. The phrase or the risk
thereof includes any process variation for
which a recurrence would carry a significant
chance of a serious adverse outcome.

(Coe CP., Uselton JP. Preparing the Pharmacy:Continuous

compliance with Joint Commission Standards. 6th ed. ASHP 2005)

 PE

PE= prescribing error

 PE

drug interaction software

PE= prescribing error

 PE

DOS

prn,

LASA drugs

PE= prescribing error

 PE

automatic stop

./

PE= prescribing error

.

.

M-reconcile
pADEs

Medication reconciliation

last dose

A formal process of obtaining a complete and

accurate list of each patients current home
medications including name, dosage,
frequency and route and comparing
admission, transfer, and/or discharge medication
orders to that list. Discrepancies are brought to
the attention of the prescriber and, if
appropriate, changes are made to the orders.
Any resulting changes in orders are documented.

(www.IHI.org Accessed 8/6/2004)

last dose

(
)

(www.IHI.org Accessed 8/6/2004)


MEDICATION RECONCILIATION AND
DISCHARGE MEDICATIONS

All inpatient and outpatients who convert

to inpatient will have all medications
reconciled within 24 hours of admission.
The final outcome of this activity is to
generate the most accurate medication
list available.
( Luther Midelfort, Mayo Health System)


An adverse drug event or ADE is defined as
a medication incident causing an injury
large or small. A potential adverse drug
event or PADE is defined as a medication
incident causing no observable injury,
including those discovered and corrected
before reaching the patient.


Medication reconciliation will be an
interdisciplinary process between patient,
physician, pharmacy and nursing
designed to decrease adverse drug events
or potential adverse drug events and
provide the most therapeutic outcome.

OTC,


The Formal three steps
Verification (Collecting a complete and accurate
list of each patients current medications:

including name, dosage, frequency, and route)

Clarification (Comparing the physicians
admission, transfer or discharge medication
orders to that list)
Documentation (Resolving any discrepancies
that may exist between the medication list and
physician order before an adverse drug event
can occur)

. .


Patients will have all medications reconciled
within 24 hours of admission.
Antibiotics, insulins, multiple dose
antihypertensives, antirejection medicines,
antiarrhythmics, inhalers, antiseizure meds,
antianginals, eye medications, pain
medications, and multiple dose oral
hypoglycemics are to be reviewed within 4
hours.

RM/

RM/


/

admission medication
reconciliation list

PCT


RI

metformin

PCT
glucose-insulin-potassium infusion

24

DOS

reconcile

MAR

discharge
counseling

/

caregiver

reconcile

4 .
4 . 24
. 24 .

reconcile

DOS

(discharge
order)
.
( MAR)


Med.
Reconcile


Med
reconcile,