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Nursing: Universal Protocol and Skills Update, Medicine, Page 5

Nursing: Universal Protocol and Skills Update

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MEDICATION RECONCILIATION
Goal #8 of the Hospital National Patient Safety Goals is to accurately and
completely reconcile medications across the continuum of care. There are a number of
steps that medical providers must follow to assist ARMC in reaching this goal.
1. With an increasing number of sound-alike, look-alike drugs on the market,
medication orders need to be written legibly, clearly specifying the dosage form,
drug strength and the purpose of the medication.
2. Do not use unacceptable abbreviations (see following list).
3. When receiving telephone orders, the nurse writes and then reads the drug, dosage, etc,
back to the medical provider for a final verification.
4. On admission, whether through the emergency department, same day surgery or a direct
admission, the nurse and the medical provider need to reconcile the
medications the patient was taking before admission to the ones to be continued in the
hospital or newly added to the list.
- "Meds from home" orders are not acceptable
5. Whenever a patient is transferred to another nursing unit within the facility, the nurse and
the medical provider need to reconcile the medications the patient needs to be taking
on the next unit before the transfer occurs. This includes:
- Any transfer to a higher or lower level of care.
- If the patient remains on the same unit but the status has changed, e.g.,
telemetry is discontinued.
- Following any operative or invasive procedure.
- "Resume pre-op" orders or "discontinue tele meds" are not acceptable.
6. When the patient is discharged from the inpatient unit to home, acute rehab, ECF or other
outside level of care, the nurse and the medical provider need to reconcile the
medications that the patient will need to take.
- "Continue home meds" orders are not acceptable.
Patient recovery from surgery or illness is a worthy goal, but it must be accomplished in the
safest possible environment. All healthcare disciplines need to work together.

 
 
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