Rules and Regulations 2013 - North Florida Regional Medical Center

North Florida Regional Medical Center
Rules And Regulations
D.7.
Medication From Other Sources – For the safety of the patient no medications
acquired by a practitioner from sources other than the hospital for use in patient
care in the hospital may be administered. Should there be needed exceptions, due
to non-availability, the practitioner will contact the Director of Pharmacy.
D.8 Medication Reconciliation - Applies to all personnel and all areas of NFRMC
where a patient presents to the hospital and will receive any medication including
radiopharmaceuticals. The purpose is to assure that the physician is aware of all
medications that the patient is currently taking and makes an informed decision
regarding continuation or discontinuation of those medications while the patient is
in the hospital.
Medication reconciliation, a national patient safety goal and standard of care, is
the process of identifying the most accurate list of all medications a patient is
taking including name, dosage, frequency and route. The list should include
prescription medications, sample medications, vitamins, nutraceuticals, over-thecounter
drugs, vaccines, diagnostic and contrast agents, radioactive medications,
respiratory therapy-related medications, parenteral nutrition, blood derivates,
intravenous solutions (plain or with additives) and any product designated by the
FDA as a drug. Medication reconciliation occurs for all patients who present to
NFRMC for care as an inpatient, observation patient, outpatient surgery or
procedure, senior healthcare center visit, or clinic visits such as wound care,
hyperbarics, cyberknife, and the obesity center (list may not be all inclusive).
It is the policy of NFRMC to accurately and completely reconcile medications
across the continuum of care. All members of the medical staff are expected to
actively participate in this process.
Inpatient Reconciliation
On admission to the hospital:
Every patient that is admitted as an inpatient will have a complete list of
their current medications compiled and documented in the Meditech
“Patient Home Medication” section. The physician or other qualified
healthcare provider is responsible for signing the printed home medication
list indicating reconciliation; changes may be made directly on the list by
the physician if desired.
On transfer to another level of care: Medication orders will be reviewed
and re-ordered by the physician prior to the patient being transferred from
one level of care to another such as from ICU to the floor or the floor to
ICU.
On discharge from the hospital: Upon discharge from the hospital, the
physician must review the patient’s admission home medications and
current hospital medications to determine if they should be continued,
discontinued or changed. This list must be completed by checking in the
appropriate columns and signed by the physician.
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