Name of the Procedure:

One high-risk medication not ordered (HCPCS G9366)

Summary

This procedure involves a healthcare evaluation confirming that a high-risk medication was not prescribed to a patient. High-risk medications can have significant side effects or interactions, and avoiding their use may be beneficial for certain patients.

Purpose

The purpose of this procedure is to improve patient safety and reduce the likelihood of adverse drug events by ensuring that potentially harmful medications are not prescribed when safer alternatives exist.

Indications

• Specific Symptoms/Conditions: Patients who have conditions that may worsen with high-risk medications or those with a history of adverse reactions to such medications.
• Patient Criteria: Older adults, patients with multiple chronic conditions, or those on multiple medications may particularly benefit from this assessment.

Preparation

• Pre-Procedure Instructions: There is typically no special preparation required from the patient. However, a thorough review of the patient's medical history and current medications is essential.
• Diagnostic Tests: No specific tests; however, a comprehensive medication review and patient assessment are conducted.

Procedure Description

1. Patient Review: The healthcare provider evaluates the patient's medical history, current medications, and potential risks.
2. Decision Making: An informed decision is made that a high-risk medication is not necessary for the patient's treatment plan, opting for safer alternatives if needed.
3. Documentation: The decision and rationale for not prescribing the high-risk medication are documented in the patient's medical record.

Duration

This evaluation typically takes place during a standard medical appointment, which could range from 15 to 30 minutes depending on the complexity of the patient's medical history.

Setting

The procedure is usually performed in an outpatient setting, such as a doctor's office, clinic, or via telehealth services.

Personnel

• Healthcare Professionals Involved: Physicians, nurse practitioners, or pharmacists who are qualified to assess medication risks and patient safety.

Risks and Complications

• Common Risks: Minimal to none, as this procedure aims to avoid the risks associated with high-risk medications.
• Rare Risks: There are no significant risks directly related to this evaluation.

Benefits

• Expected Benefits: Reduced risk of adverse drug reactions, improved overall patient safety, and more effective and safer medication regimens.
• Timeframe: Benefits can be immediate upon adjusting or discontinuing a high-risk medication.

Recovery

• Post-Procedure Care: No specific recovery is needed; normal activities can be continued.
• Follow-Up: Follow-up appointments may be necessary to monitor the patient’s response to the alternative treatments and overall health.

Alternatives

• Other Treatment Options: Potentially prescribing the high-risk medication with close monitoring, using lower-risk medications, or non-pharmacological treatments.
• Pros and Cons: Alternatives should be weighed based on the patient's specific health needs and risks, with the goal of optimizing both safety and effectiveness.

Patient Experience

• During Procedure: The evaluation process should be straightforward and comfortable, involving conversations and reviews of medication history.
• After Procedure: Patients may feel reassured by the proactive approach to their health and safety. There should be no pain associated with this procedure, and any concerns about medication adjustments can be addressed during the follow-up.