Pharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02

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1 Pharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02 V02 issued Issue 1 May 11 Issue 2 Dec 11 Planned review May 2014 Responsible officer Medical Director PPT-PGN-11 Part of NTW(C)38 Pharmacological Therapy Policy Contents Section Description Page No 1 Introduction 1 2 Roles and responsibilities 2 3 Collecting information 3 4 Checking reconciliation of a medication history 4 5 Communicating an accurate medication summary 5 6 Communicating medication changes on discharge 6 7 Audit 6 8 References 6 Appendices 1 Processes involved in medicine review 2 Sources of information available to aid the compilation of a medication history 3 NICE Medicines Reconciliation Audit Tool 1 Introduction 1.1 In December 2007, the National Institute for Health and Clinical Excellence (NICE) in collaboration with the National Patient Safety Agency (NPSA) issued guidance to the NHS on how to improve the process of medicines reconciliation¹. The guidance focuses specifically on medicines reconciliation for adults on admission to hospital. The guidance is intended to ensure that any medicines service users are taking prior to a hospital admission are accurately documented. 1.2 Medicines Reconciliation has been defined by the Institute of Healthcare Improvement (I.H.I.) as being the process of identifying the most accurate list of a service user s current medicines including the name, dosage, frequency, and route and comparing them to the current working list². This enables any discrepancies to be recognised and changes to be documented resulting in a complete list of medications. 1

2 1.3 Medicines reconciliation can occur when service user s are: Admitted to hospital Transferred to other units within a hospital Transferred to another hospital Discharged from hospital 1.4 Factors that may contribute to medicines reconciliation errors include the following: No access to the service user s prescription list from primary care. Discrepancies between the primary care prescription list and the medications the service user is taking. This may happen because the service user is no longer taking prescribed medications, because they are taking medications they have obtained themselves (for example, over-the-counter medicines, herbal medicines or vitamins), or because they are taking the incorrect dose. Service users may be prescribed medicines by hospital specialists and these items may not appear on the primary care list. Difficulties in obtaining an accurate account of a service user s medication, which may be caused by an acute condition, sensory or cognitive impairment, lack of access to family or carer support, or language barriers. Errors in transcribing medication details to the hospital clinical record. 1.5 Inaccurate medication reconciliation can lead to errors that may be detrimental to a service user s health. 1.6 Initial inaccuracies in a medication reconciliation can be carried through the inpatient journey, replicated on the discharge notification and then passed back into primary care. 1.7 This practice guidance note describes the steps that must be followed to ensure a medication reconciliation is taken and compiled in an accurate manner. An accurate medication history may then be used to identify previous sub-optimal dosing, premature discontinuation of treatment and alert staff to any problems the service user may have had in the past, for example, side effects or allergies. 2 Roles and Responsibilities 2.1 Medication reconciliation will be conducted by clinical pharmacy staff. 2.2 Medical and nursing staff have an important role in ensuring that medication reconciliation is a component of the admission and clerking process of all service user s. 2

3 2.3 Pharmacists should be involved in medicines reconciliation as soon as possible after a service user as been admitted depending upon local arrangements. 2.4 The processes involved in the medicines reconciliation are listed in appendix The Medical Director has overall accountability for the policy and practice resulting from the implementation of this practice guidance note. 2.6 Service Managers should review and monitor the policy ensuring safe implementation in all areas. 3 Collecting Information 3.1 The National Prescribing Centre describes three processes involved in medication reconciliation as collecting, checking and communicating Collecting involves the compilation of the medication history and other relevant data for all newly admitted service users. 3.3 Information can be obtained from a number of sources. (See Appendix 2) 3.4 Establish exactly what the service user does with their medication as this could vary from formal records. 3.5 Review the service user s medical notes to ascertain most recent medicine specific information i.e. a recent discharge summary or clinic entry. 3.6 Identify the relevant GP information (name, address and telephone number) together with the service user s full name, address and date of from the notes/rio system or after discussion with the patient and their carers. 3.7 Telephone the GP surgery and request a medication summary including allergy status be faxed to a designated safe facsimile machine. 3.8 The summary obtained in step 3.8 should include repeat and acute medication. This information should include: Drug name Form Strength Dose Date of last issue Number of days supply issued 3.9 All known allergies, hypersensitivities and documented previous adverse reactions must also be noted including details/severity/of the reactions where known. 3

4 3.10 Allergy status must be documented in the clinical notes and on the front of the inpatient treatment chart. Where this information is missing members of the pharmacy team (clinical technicians and clinical pharmacists) should confirm allergy status, document the chart accordingly signing and dating the entry As this is a process to confirm all regular medication a service user is taking, a range of sources/ types of medication may need to be taken into consideration including: Those medicines prescribed by the service user s GP, practice nurse, dentist or Practice pharmacist Those medicines prescribed by hospital specialists Those medicines prescribed by community based teams Over the counter (OTC), vitamins and herbal medicines Recreational drugs. Smoking status 3.12 The various sources of information available to compile or confirm a service users medication history have variable levels of reliability. At least two sources of information should be used to complete and accurate medicines reconciliation Any source of information used to compile or confirm a service user s medication history must be accurate and current. Professional judgement must be employed to ascertain how reliable a particular source of information is Staff should discuss current medications with the service user and or their carer to clarify their current medication regime Any medicines bought over the counter from pharmacies should be recorded Any herbal remedies or supplements should be recorded Any compliance issues should also be highlighted e.g. the use of a compliance device; whether the service user omits medicine(s) or has altered the dose with or without informing the prescriber Where possible the service user s regular community pharmacy should be identified. 4 Checking Reconciliation of Medication History 4.1 Reconciliation of medication is the process of comparing the sources of information obtained to either: accurately compile the service users current medication ahead of prescribing or compare the compiled medication history with those medicines prescribed on the inpatient prescription chart 4

5 4.2 Any identified discrepancies or safety issues must be brought to the attention of the medical staff responsible for the service users. 4.3 Any medication required for the service user that is not available on the ward should be obtained from pharmacy according to policy. 5 Communicating an Accurate Medication Summary 5.1 The medication reconciliation and the sources used must be recorded in the current medication section of the service user s record (paper or electronic), chronologically in the progress notes, or in pathway documentation where in use. This may vary according to clinical area The entry should be titled Medicine Reconciliation Note if the current medication section in a pre-printed document will become too cluttered or unclear by any additions then a record must be made that the medication reconciliation has been updated chronologically in the progress notes or pathway. This will ensure that the correct information is available for preparation of the discharge summary. 5.2 The entry must be signed, timed and dated by the person(s) compiling the history Where paper records are used the entry must be signed, timed and dated by the person(s) compiling the history Where electronic records are used pharmacy staff should ensure that the record they make contains their name, job title and pharmacy. Date and time will also be recorded. 5.3 The designation and bleep number (if applicable) must also be documented. 5.4 Any medication changes must be documented in a clear legible format in the current medication section of the service user s notes or chronologically in the progress notes. Examples include: When a medicine was stopped or started stating the reason Duration of treatment if short term e.g. antibiotics Changes to dose/route/frequency stating the reason The patient summary from the GP should be filed in the medical notes or scanned into the electronic record 5.5 Any problems requiring further investigation or intervention by the medical team must be documented chronologically in the medical or progress notes. 5.6 Where ward based clinical pharmacy staff is available they will ensure all necessary steps have been followed to ensure the information on the medicine chart is accurate. 5

6 5.7 The clinical pharmacist will then validate or clinically screen the chart by signing and dating each medication prescribed on the chart. 6 Communicating Medication Changes on Discharge 6.1 Any medication changes during admission should be documented using the interim discharge summary form or in the discharge letter. 6.2 Details should include whether medication has been started, stopped or if a dose has changed during admission including any reason or rationale for the change if apparent. 7 Audit 7.1 NICE have produced an extensive audit tool see Appendix 3. Required information includes: 7.2 The percentage of service users that have had their medicines reconciled 24 hours of admission by medical or nursing staff. 7.3 The percentage of service users that have had their medicines reconciled a pharmacist or pharmacy technician within 24 hours of admission. 7.4 The percentage of service users that required one or more change to their medication following medicines reconciliation by a pharmacist or pharmacy technician. 7.5 The percentage of hospital admissions that are able to obtain a Medication summary from their GP within 24 hours. 8 References National Institute of Health Clinical Excellence + National Patient Safety Agency - Technical Patient Safety Solutions for Medicines Reconciliation on Admission of Adults to Hospital. Nice Patient Safety Guidance 1, Accessed 16 th May 2008 Institute for Healthcare Improvement, Accessed 16th May 2008 National Prescribing Centre. Patient Safety and Risk. Reconciliation Learning Objectives and Impact Assessment. obj_impact assess1.php accessed 19th November

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