All patients will have a medication reconciliation performed:
- Upon admission (within 24 hours whenever possible)
- At transfer to different settings and/or level of care
- At discharge
Reconciliation is a three-step process to prevent:
- Duplication of therapy
- Adverse interactions with other medications
- The nurse, pharmacist or pharmacy technician will obtain a list of medications from the patient to be reviewed by the physician for completeness and accuracy.
- Physician(s) will indicate in the EMR which home medications to continue or discontinue upon admission.
- A pharmacist is responsible for identifying duplication or potential drug interactions when verifying medication orders.
- Physicians are responsible for collaborating with nurses and pharmacists in all steps of the process.
- The physician will reevaluate all medications at discharge.