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Background
Medication reconciliation is a critical process in healthcare aimed at ensuring the accuracy and safety of a patient’s medication regimen during transitions of care. These transitions can occur when a patient moves from one healthcare setting to another, such as from home to the hospital, between different healthcare facilities, or during discharge from a hospital or clinic.
The primary goal of medication reconciliation is to prevent medication errors, adverse drug events, and potential harm to the patient by creating and maintaining an accurate and up-to-date list of the patient’s medications. This process involves comparing the patient’s current medication regimen with any newly prescribed medications, as well as reconciling any changes that may have occurred during the course of their care.
Key components of medication reconciliation include:
1. Compilation of Medication List:
* Gathering a comprehensive list of all the medications a patient is currently taking, including prescription medications, over-the-counter drugs, herbal supplements, vitamins, and any other relevant substances.
2. Verification:
* Cross-referencing the compiled list with various sources, such as the patient, family members, pharmacy records, and the electronic health record (EHR). This helps identify any discrepancies or differences in medication information.
3. Reconciliation:
* Resolving any identified discrepancies and creating a final, accurate list of the patient’s medications. This may involve updating the medication list to reflect changes in dosage, frequency, or discontinuation of medications.
4. Communication:
* Sharing the reconciled medication list with the patient, as well as healthcare providers involved in the patient’s care. Clear communication is essential to ensure that everyone is aware of the accurate medication information.
5. Documentation:
* Recording the entire medication reconciliation process in the patient’s health record. This documentation serves as a reference for healthcare providers involved in the patient’s care and supports continuity of care.
Medication reconciliation is especially important during transitions of care because misunderstandings or omissions in a patient’s medication list can lead to medication errors, adverse drug reactions, hospital readmissions, and compromised patient safety. By systematically reviewing and updating the medication regimen, healthcare professionals can help ensure that patients receive the right medications at the right doses and frequencies, promoting effective and safe healthcare delivery.
Assignment
Overview:
This assignment is designed to help develop and demonstrate your skills in medication reconciliation, ensuring patient safety and continuity of care. In this assignment, you will be given a scenario and a patient that you will be “seeing” in the clinical setting. You will be reviewing that patient’s home medication list and comparing the list to your admission orders. After reviewing the two lists and taking a deep dive into the medications listed, you will create a list of recommendations to bring up with the patient’s Primary Healthcare Provider when they round on your patient for the day, addressing any missing medications or safety issues.
Scenario:
Mary Ann is a 68-year-old female with a past medical history of hypertension, hyperlipidemia, and Type II Diabetes. She also has chronic arthritic knee pain, which she manages with over-the-counter medications. She denies using alcohol and has no known allergies. She presented to the hospital with severe flank pain and had a CT scan of the abdomen with IV contrast, which showed a large left-sided kidney stone with ureteral obstruction. She is being admitted to the medical floor and will be having a lithotripsy in the morning.
Her blood pressure is 155/68, heart rate is 62, Temperature is 99.0, and respiratory rate is 20 and non-labored. She is alert and oriented, has a normal S1 & S2, and has no murmurs. She has clear lung sounds bilaterally. She has normal bowel sounds. Her extremities are warm with 2+ Radial and DP pulses. She has bilateral 2+ lower extremity edema. She is currently reporting an 8/10 pain in her left abdomen/flank area. She has a BMI of 38. She lives alone at home. Her husband died several years ago, and she has two daughters who live out of state. Her morning lab work showed abnormal values of a WBC count of 15,000, Creatinine of 2.4, and a glucose of 210. All other labs were normal.
Home medications:
* Aspirin 81 mg PO 1xD
* Metformin 500mg PO 2xD
* Lisinopril 40mg PO 1xD
* Metoprolol 50mg PO 2xD
* Ibuprofen 600mg PO q6h PRN
* Tylenol 500mg PO q6h PRN
* Atorvastatin 40mg PO 1xD taken in the evening
* Multivitamin PO 1xD
Inpatient medication orders:
* Aspirin 81 mg PO 1xD
* Metoprolol 75mg PO 2xD
* Tylenol 650mg PO Q6H PRN for mild pain 1-3 out of 10
* Atorvastatin 40mg PO 1xD QPM
* Humalog insulin sliding scale (SC) ACHS
* Glu<60 call provider
* Glu 61-150 No Coverage
* Glu 151-200 2 Units SC
* Glu 201-250 4 Units SC
* Glu 251-300 6 Units SC
* Glucose >300 call provider
* Heparin 5000 units Q8H SC
* Lasix 20mg PO 1xD
Assignment Tasks:
In an MS Word document, please complete the following tasks:
Section 1. Home Medication List Rationale:
In paragraph form, look at each medication on the home medication list and give a brief overview of each medication including the drug class, indication for administration (what medical diagnosis in the scenario is the drug treating specifically), safe dose range compared with current dose, basic medication administration details, most common and life-threatening side effects, and monitoring parameters (labs, vital signs, physical assessment findings, etc.) You should have at least 1 paragraph for each medication you are reviewing. All information in this paragraph should be cited with an appropriate reference (Nursing Drug Guide, Pharm/Med Surg Textbook, ATI Book, etc. – please do not use websites like drugs.com, WebMD, etc.)
Section 2. Hospital Medication List:
Your patient has been admitted to the hospital and you have your inpatient admission medication orders. Review this list and, in paragraph form, answer the following questions.
– Are there any home medications missing? If yes, do you think they were omitted for safety reasons? Vital sign abnormalities? Lab abnormalities? Or was it an accidental omission?
– Are there any medications ordered that are not on the home medication list? If so, why do you think this medication was ordered? For new medications give a medication overview similar to section 1, with rationale for why the medications are ordered.
– Are there any medications that are not on either list that you believe should be included on the patient’s medication list (PRN medications, prophylactic medications, etc).
Provide rationale (with a cited resource) on how you support your information in this section.
Section 3. Compile a final medication list for the inpatient stay to recommend to the patient’s primary healthcare provider based on the first 2 sections. This section can just be a list of medications, similar to the ones you received in the initial scenario. Your rationale should be provided in the above sections.
Your paper should be written in current APA 7format and have a title page, a body with the 3 sections above, and a reference page. Please make sure all references are cited appropriately within your paper. Please reach out to the writing center for assistance with APA 7 format or completing the assignment if needed.
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