A Best Practice Resource and Toolkit

Transcription

1 pecialist Pharmacy ervice Medicines Use and afety Improving the Quality of Medicines Reconciliation A Best Practice Resource and Toolkit Version 1 June 2015 pecialist Pharmacy ervice Winner: Dressings, PrescQIPP Innovation awards 2013; Winner: RP Pharmaceutical Care Award 2013 Finalist: HJ Patient safety in primary care award 2013; Winner: UKCPA/Guild Conference Best Poster award 2013

2 Medicines Use and afety Introduction The importance and effectiveness of a robust and rigorous Medicines Reconciliation (MR) within all care settings is vital to ensuring patient safety. Medicines Reconciliation is recognised globally as a process that supports patient safety. The World Health Organisation (WHO) have identified Medicines Reconciliation as a priority for action as part of its High 5s Project that was launched in 2006 to address continuing major concerns about patient safety around the world. imilarly, many national organisations such as the National Institute for Health and Care Excellence (NICE), National Patient afety Goals of the Joint Commission in the UA, the Patient afety Institute and the Institute for afe Medication Practices in Canada have all issued guidance and directives to support the Medicines Reconciliation agenda. In addition an effective Medicines Reconciliation process significantly supports the delivery of many of the outcomes associated with the Medicines Optimisation principles as described in the Royal Pharmaceutical ociety Medicines Optimisation Guidance. Medicines Reconciliation is often the first step or opportunity to understand the patient s experience of their medicines, this can then lead to ensuring that patients take their medicines correctly, avoid taking unnecessary medicines, reduce wastage of medicines, ensure that medicines are prescribed and taken safely and improve outcomes from medicines use. Despite the high status of Medicines Reconciliation as a patient safety issue and efforts to implement robust Medicines Reconciliation processes, a consensus statement from key stakeholders has called for further efforts to identify best practices surrounding Medicines Reconciliation and their wider dissemination. Whilst the majority of secondary care NH providers have Medicines Reconciliation processes in place, this best practice resource/toolkit will help organisations evaluate the effectiveness of existing processes, identify and respond to any gaps in service provision and support improvements in current Medicines Reconciliation processes all with an aim to improve patient safety within the organisation. The resource is divided into six chapters and aims to: Allow senior Pharmacists to make a case for resources to support Medicines Reconciliation within the organisation from a perspective of patient safety and return on investment Generate discussion between senior Pharmacists and their multidisciplinary colleagues to improve Medicines Reconciliation processes within the organisation Allow standardisation and establishment of best practice for Medicines Reconciliation within and across organisations Provide tools to audit and evaluate Medicines Reconciliation processes within the organisation Provide a framework to ensure that staff are fully trained and competent to deliver Medicines Reconciliation Provide an introduction to quality improvement methodology in the context of Medicines Reconciliation The Medicines Use and afety team would be grateful if you could provide feedback on this resource by completing the online feedback survey by clicking Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 2

3 Medicines Use and afety Acknowledgements The development of this best practice resource/toolkit has been supported by a group of talented and knowledgeable individuals from across the NH, Academia, Educational Organisations and Health Research Groups whose expertise, knowledge and contribution has been invaluable. Members of the working group and their affiliated organisations are detailed below: Chetan hah (Project Lead) Chinedu Ahamefula Diane Blunden Fiona Turnbull Jane Hough Julia Wright Dr Julie Reed Kristi Anderson Krupa Patel Laura McEwen-mith Matthew haw Michelle ullivan Medicines Use and afety Division, NH pecialist Pharmacy ervice Moorfields Eye Hospital, Moorfields Eye Hospital NH Foundation Trust London Pharmacy Education and Training (LPET) Northwick Park Hospital, London Northwest Healthcare NH Trust Medicines Use and afety, NH pecialist Pharmacy ervice Medicines Use and afety, NH pecialist Pharmacy ervice Northwest London CLAHRC Northwick Park Hospital, London Northwest Healthcare NH Trust Hounslow CCG Health Education Kent, urrey & ussex Pharmacy Centre for Pharmacy Postgraduate Education (CPPE), University of Manchester London Chest Hospital, Barts Health NH Trust Mildred Johnson Nadine Hall Nikki Ayres Dr Nkiruka Umaru Nita anghera Oilin Man Patrick Karikari arah Gray hirley Kuo Vimal riram Wendy Cossey Moorfields Eye Hospital, Moorfields Eye Hospital NH Foundation Trust Luton and Dunstable NH Foundation Trust t George s Hospital, t George s University Hospitals NH Foundation Trust Department of Pharmacy, University of Hertfordshire Kingston Hospital NH Foundation Trust Bedford Hospital NH Trust Newham CCG Addenbrooke's Hospital, Cambridge University Hospitals NH Foundation Trust Northwest London CLAHRC Northwest London CLAHRC Joint Programmes Board (JPB) Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 3

4 Contents Medicines Use and afety Introduction Page 2 Acknowledgements Page 3 Chapter 1 Making the Case for Medicines Reconciliation Page 5 Chapter 2 Definition of Medicines Reconciliation and Process haring Page 18 Chapter 3 Best Practice tandards Page 36 Chapter 4 Audit and Evaluation Page 59 Chapter 5 Education, Training and Competency Page 76 Chapter 6 Quality Improvement Methodology Page 95 {Authored by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North West London (NWL)} Appendices Appendix 1 Medicines Reconciliation on Admission Audit Data Collection Tool Page 117 Appendix 2 Medicines Reconciliation on Discharge / Discharge ummaries Audit Data Collection Tool Page 120 Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 4

5 Chapter 1 Making the Case for Medicines Reconciliation Medicines Use and afety The aim of this chapter is to set out an evidence based argument for providing a robust Medicines Reconciliation service to patients. A crucial element of having a robust and effective Medicines Reconciliation process/service is to have support within the organisation especially from physicians, nurses, budget holders and risk managers. In order to gain this support from within the organisation Medicines Reconciliation should be discussed in the context of (i) being linked to NH policy and practice, (ii) being a patient safety issue and lastly as a (iii) return on investment. 1.1 Medicines Reconciliation and NH Policy and Practice In the National Patient afety Agency (NPA) and the National Institute for Health and Care Excellence (NICE) published a patient safety guidance titled Technical patient safety solutions for Medicines Reconciliation on admission of adults to hospital. The guidance recommended that: All healthcare organisations that admit adult inpatients should make sure that they have policies in place for Medicines Reconciliation on admission. This includes mental health units, and applies to elective and emergency admissions. In addition to specifying standardised systems for collecting and documenting information about current medications, policies for Medicines Reconciliation on admission should ensure that: o Pharmacists are involved in Medicines Reconciliation as soon as possible after admission o The responsibilities of Pharmacists and other staff in the Medicines Reconciliation process are clearly defined; these responsibilities may differ between clinical areas o trategies are incorporated to obtain information about medications for people with communication difficulties. ince then organisations have focused Pharmacy resource into delivering Medicines Reconciliation (MR) within 24 hours of admission. The more recent NICE Guidance - Medicines Optimisation: the safe and effective use of medicines to enable the best possible outcomes 2 which was published in March 2015 states that: In an acute setting, accurately list all of the person's medicines (including prescribed, over-thecounter and complementary medicines) and carry out Medicines Reconciliation within 24 hours or sooner if clinically necessary, when the person moves from one care setting to another for example, if they are admitted to hospital Recognise that Medicines Reconciliation may need to be carried out on more than one occasion during a hospital stay for example, when the person is admitted, transferred between wards or discharged In primary care, carry out Medicines Reconciliation for all people who have been discharged from hospital or another care setting. This should happen as soon as is practically possible, before a prescription or new supply of medicines is issued and within 1 week of the GP practice receiving the information In all care settings organisations should ensure that a designated health professional has overall organisational responsibility for the Medicines Reconciliation process Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 5

6 Medicines Use and afety Organisations should ensure that Medicines Reconciliation is carried out by a trained and competent health professional ideally a Pharmacist, Pharmacy technician, nurse or doctor with the necessary knowledge, skills and expertise Involve patients and their family members or carers, where appropriate, in the Medicines Reconciliation process When carrying out Medicines Reconciliation, record relevant information on an electronic or paperbased form. In addition to the national drivers detailed above Medicines Reconciliation is a key performance indicator that is measured on the NH England Medication afety Thermometer, NH England Medicines Optimisation Dashboard and in contract monitoring agreements between Clinical Commissioning Groups (CCG) and secondary care providers. From a professional perspective Medicines Reconciliation forms a crucial element of the Royal Pharmaceutical ociety (RP) Hospital Pharmacy tandards (tandard 2.1) which state that patient s medicines should be reviewed for an accurate medication history, for clinical appropriateness and to identify patients of further Pharmacy support. 1.2 Medicines Reconciliation as a Patient afety Issue Medication errors are one of the leading causes of injury to hospital patients, and chart reviews reveal that over half of all hospital medication errors occur at the interfaces of care 3. The prevalence of medication discrepancies arising at transitions of care have been reported in many different settings (hospital, community and long-term care facilities) and stages of care (admission, transfer and discharge). When a patient s transition from the hospital to home is inadequate, the repercussions can be far-reaching hospital readmission, an adverse drug event, and even mortality 4, 5. everal national European studies of adverse events revealed that between % of hospitalised patients have suffered at least one adverse event during their admission and that between % of these adverse events were caused by medications which were preventable 6. imilar research suggests that the average hospitalised patient is subject to at least one medication error per day 7, which confirms previous research findings that medication errors represent one of the most common patient safety breaches 8. Quite pertinently, more than 40 percent of medication errors are believed to result from inadequate reconciliation in handovers during admission, transfer, and discharge of patients of which approximately 20 percent are believed to result in patient harm 9, 10. In the UK, the Medicines Use and afety Division 11 conducted a collaborative audit centred on MR across 56 NH trusts across East and outh East of England covering 33,120 beds. Of the 8621 Medicines Reconciliations audited that includes 49,099 admission drugs (average of 5.7 drugs per MR) approximately 11,366 unintentional discrepancies (UDs) were identified (mean 1.32 per MR) between the medications charted at admission and what should have possibly been charted. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 6

7 Medicines Use and afety 1.3 Medicines Reconciliation and Return on Investment uccessful implementation of Medicines Reconciliation services requires leadership and adequate resources to support the process. Therefore a strong business case that demonstrates the patient safety and financial benefits to the organisation which can justify the resources required is extremely important. Although there is a significant body of evidence that supports the case for Pharmacist led MR from a patient safety perspective, it is rather more difficult to quantify the cost benefits derived from implementing robust Pharmacist led MR. Despite being unable to quantify direct cost savings from Pharmacist led MR, there is the potential to calculate a monetary figure that might be termed cost avoidance. This can be defined as the cost avoided by preventing a preventable ADE which would result in an increased length of stay or increased use of staff or laboratory or other monitoring resource. Cost avoidance can be translated into cost effectiveness. Calculations of cost effectiveness underpinned the review which led to the 2007 Medicines Reconciliation NPA/NICE Guidance. In the two figures below, an evidence based attempt is made to demonstrate the return on investment when pursuing funding for Pharmacy led Medicines Reconciliation support. The examples are focussed on Pharmacy led MR for unplanned admissions, calculations could be similarly conducted for planned admissions however, the Pharmacy resource must be adjusted to 5 min per Medicines Reconciliations as per NICE 2007 guidance. Fig 1.3.1: Calculating Pharmacist resource and net return on investment for Pharmacy led MR using detailed published parameters By using published MR discrepancy/error data it is possible to calculate the number of harmful medication errors per year that can be avoided by undertaking a Pharmacy led Medicines Reconciliation. Then by applying a monetary amount (evidence based) to each potential adverse drug event (ADE) prevented, a gross annual savings amount can be calculated on the premise that those ADEs are fully avoided by undertaking a Medicines Reconciliation. The costs of a Pharmacy led MR service can be calculated using the NICE guidance estimations on the time taken to conduct MR. By undertaking the above calculations in the context of the admission data for the organisation which is available from the organisations information team the costs and savings can be calculated in a bespoke manner for the organisation in a fully evidence based manner and included in any business cases. By subtracting the costs of the Pharmacy staff from the annual gross savings of preventing ADEs a net return on investment can be calculated. The table below sets out the calculations (with evidence based footnotes) that are required to be followed to achieve the aims sets out above. Measures Average no of MR 1.32 discrepancies per patient Calculations Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 7

8 Medicines Use and afety Number of unplanned admissions per year (X) Number of MR medication errors avoided per year Type (categorised by severity of possible harm) and frequency of MR discrepancies Cost avoided as a result of medication errors prevented Annual gross savings to hospital (utilising the absolute lower end of the above range) Number of MR that can be undertaken by a 1.0WTE member Pharmacy staff per year π Cost of Pharmacy staff resource required Annual Cost Benefit Notes: X X(1.32) = Y Level 1 Errors 60% Level 2 Errors 36% erious Errors 4% Level 1 Errors 0-6 Level 2 Errors erious Errors (Y x 0.6 x 0) + (Y x 0.36 x 65) + (Y x 0.04 x 713) Notes: 0.6 (frequency) and 0 (cost avoided) = Level 1 errors 0.36(frequency) and 65 (cost avoided) = Level 2 errors 0.04(frequency) and 713 (cost avoided) = Level 3 errors 4 x 7 x 5 x 4 x 12 = 6720 MR per year X / 6720 = Z (No of Pharmacy staff required) Z x AfC salary banding = Pr (Y x 0.6 x 0) + (Y x 0.36 x 65) + (Y x 0.04 x 713) Pr 1.32 is based on Dodds L. Results of a Collaborative Audit of Pharmacy-led Medicines Reconciliation (MR) in 56 trusts across E & E England. Medicines Use and afety Division, East and outh East pecialist Pharmacy ervices Obtain X from NH information team (could be for particular care area/ward or entire hospital) Categorisation of errors is based on NRL rating scale and frequency of error rate is calculated based upon the study by Dodds L. Which patients benefit most from Medicines Reconciliation? A collaborative evaluation of the outcomes of Pharmacy-led Medicines Reconciliation in various care areas 13 Costs obtained from Campbell F, Karnon J, Czoski-Murray C, Jones R. ystematic review for clinical and cost effectiveness of interventions in Medicines Reconciliation at the point of admission (2007). The University of heffield, chool of Health and Related Research 12 A very conservative approach has been taken to costs avoided as a result of medication errors prevented, utilising the absolute lower end of the range π Calculation is based on one Pharmacy staff member taking 15 minutes to undertake a MR for an unplanned admission (as per NICE guidance 1 ) therefore undertaking 4 MR per hour multiplied by 7 hours in a day multiplied by 5 days per week multiplied by 4 weeks per month multiplied by 12 months per year When the above calculation pro-forma is applied to an Admissions Unit (In a 400 bedded District General Hospital) that has an annual unplanned admission rate of 20,807 patients per year the net return on investment is approximately 1.4million pounds (Pr Value = 116,988 - utilising a Pharmacy resource of midpoint Band 5 Pharmacy Technician, midpoint Band 6 Pharmacist and midpoint Band 7 Pharmacist). Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 8

9 Medicines Use and afety This could alternatively be expressed as for every 1 spent on Pharmacy staff conducting Medicines Reconciliation approximately 12 is saved through preventing medication related adverse drug events. Despite the evidence based nature of the example set out in in Fig 1.3a there are some limitations to be mindful of when utilising the example in business cases: The error type and frequency values utilised in the calculation which are obtained from the study conducted by Dodds 13 relied on individual practitioner self-assessment rather than peer-review of potential clinical impact which may have introduced bias There is an assumption that all the identified discrepancies are resolved appropriately and promptly and so the anticipated preventable ADE is averted In practice Pharmacy staff do not exclusively undertake MR duties, they are involved in many other activities that contribute to patient care The calculations do not factor in cost pressures such as sick leave, annual leave, study leave, absence etc. Fig 1.3.2: Model based cost-effectiveness analysis of preventing medication error at hospital admission through Pharmacist led MR ome research evidence indicates that medication errors or discrepancies are an imperfect surrogate for preventable ADEs because they are very common and only a small fraction actually cause harm. A model developed by Karnon 14 et al that proposed a baseline preventable ADE rate of 2.8 ( ) per 1000 prescription orders at a total cost of 4092 ( ). If there is an assumption that on average patients are prescribed 5 drugs ӻ this translates into an average of preventable ADE per MR at a cost avoidance of approximately 20/MR. However, not all of these medication errors will be identified by, or even related to, the MR process, therefore Karnon 14 et al extrapolated from research evidence that Pharmacists reduce the error rate by 75% and pharmacy technicians/systematic methods of recording drug histories by 50%. As most pharmacy teams use a mix of pharmacists and pharmacy technicians to undertake MR, then it would be pragmatic to conclude that Pharmacy led MR reduces the preventable ADE rate at admission to per patient. The cost avoidance is thus 10/MR. Against this must be offset the cost of the Pharmacy MR itself (15 min of B6 time plus on cost = 5), resulting in a cost avoidance per Pharmacy led MR of 5 per patient. In some health economies a proxy cost avoidance of 5/ Pharmacy led MR has been agreed to help quantify the savings associated with Pharmacy led MR. This can then be applied to admission data for the organisation. For example if the above calculation is applied to an Admissions Unit (In a 400 bedded District General Hospital) that has an annual unplanned admission rate of 20,807 patients per year the net return on investment is approximately 104,035. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 9

10 Medicines Use and afety ӻ over 75% of patients with discrepancies with the potential for moderate clinical impact in the eptember 2010 collaborative service audit were on 5 or more medicines 11 Other additional potential benefits of Medicines Reconciliation within a business case that should also be articulated are the following: Decrease in readmissions or visits to emergency departments Decrease in legal costs associated with ADEs Increased efficiencies due to streamlined processes Increased patient engagement and patient satisfaction Increased staff satisfaction Reduced re-dispensing and thus saving on drug costs and Pharmacy resource Litigation avoidance There is significant evidence that demonstrates that implementing effective Medicines Reconciliation processes are a powerful intervention to reduce medication errors. ome published MR interventions that have delivered positive outcomes are briefly described: A series of Medicines Reconciliation interventions, introduced over a seven-month period, successfully decreased the rate of medication errors by 70% and reduced adverse drug events by over 15% 15. In another study 16, the utilisation of Pharmacy technicians to initiate the reconciliation process by obtaining medication histories for the scheduled surgical population reduced potential adverse drug events by 80% within three months of implementation. A revised Medicines Reconciliation process reduced work and re-works associated with the management of medication orders. After implementation, nursing time at admission was reduced by over 20 minutes per patient. The amount of time that Pharmacists were involved in discharge was reduced by over 40 minutes 17. The implementation of a comprehensive Medicines Reconciliation program to reduce errors in admission and discharge medication orders at an academic medical centre reduced medication errors from 90% to 47% in surgical patients 18. A study 19 that observed that the introduction of Pharmacy services, which included Medication Reconciliation, into a hospital s kidney transplant team created a statistically significant decrease in the mean length of stay among transplant recipients (from 7.8 days to 3.4 days). The cost savings attributed to this decrease was estimated at $279,180 UD per year. A further study 14 conducted a cost-effectiveness analysis of interventions aimed at preventing medication errors at hospital admission. The aim of the study was to assess the incremental costs and effects (measured as quality adjusted life years) of a range of Medicines Reconciliation interventions. Findings demonstrated that all five interventions, for which evidence of effectiveness was identified, were estimated to be extremely cost effective when compared to the baseline scenario. In this paper, the Pharmacist-led reconciliation intervention had the highest expected net Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 10

11 Medicines Use and afety benefits and a probability of being cost-effective of over 60% by a quality-adjusted life year value of 10,000. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 11

12 Medicines Use and afety 1.4 International Efforts and Initiatives to Optimise Medicines Reconciliation As discussed in the introduction Medicines Reconciliation is recognised globally as a process that supports patient safety, the table below signposts to organisations across the world that have developed initiatives to improve the Medicines Reconciliation process. Much of the content and tools developed by the signposted organisations below are transferable to organisations in England and therefore may be of interest. Table 1.4: ignposting of international Medicines Reconciliation initiatives Organisation ite/name World Health Organisation s High 5s Medicines Reconciliation Project URL v.au/our-work/medicationsafety/medicationreconciliation/who-high-5smedication-reconciliationprogram/ Content and function The aim of the High 5s project was to determine: the feasibility of implementing standard operating protocols (OPs) for Medicines Reconciliation in different countries with different healthcare environments and cultures and whether the OPs are effective in improving patient safety. The Medicines Reconciliation OP addresses the prevention of medication errors resulting from incomplete or miscommunicated information at points of transition in the patient-care process, including admission, transfers to and discharge from hospital. The Australian Commission on afety and Quality in Healthcare v.au/our-work/medicationsafety/medicationreconciliation/ The Commission has several resources available on medication reconciliation: Get it right! Taking a Best Possible Medication History training video Consumer resources Match Up Medicines National Medication Management Plan World Health Organization s High 5s Medicines Reconciliation Project Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 12

13 Medicines Use and afety ociety of Hospital Medicine MARQUI program (UA) Canadian afer Healthcare Now! Medicines Reconciliation Initiative Institute for Health Care Improvement (UA) g/web/quality Innovation/I mplementation_toolkit/marq UI/Overview_Medication_Re conciliation.aspx ages/default.aspx atientafety/medicationystem s/measures/ In 2010, the Agency for Healthcare Research and Quality (AHRQ) awarded the ociety of Hospital Medicine (HM) a $1.5 million grant for a three year Multi Centre Medicines Reconciliation Quality Improvement tudy (MARQUI). The goal of MARQUI is to develop better ways for medications to be prescribed, documented, and reconciled accurately and safely at times of care transitions when patients enter and leave the hospital. Resources include an implementation manual, white paper, videos on taking a Best Possible Medication History (BPMH) and discharge counselling, BPMH pocket cards and return on investment (ROI) calculations. Home page for the Medicines Reconciliation initiative, part of the Canadian Patient afety Institute s afer Healthcare Now! Campaign (from 2005 to present). The site contains information about the initiative as well as a number of resource materials including a Getting tarted Kit, performance measures and audit tools, data entry tools, posters, reports and videos. It is also possible to join the Community of Practice, an online discussion forum for Canadian sites to share resources and information. The Medicines Reconciliation initiative has been extended to include long term care and home care. Information about these initiatives and associated resource materials are also available on the site. A range of materials available from the 5 million lives campaign ( ) including a Medicines Reconciliation How to Guide, articles, educational leaflets, webinars and sample reconciliation forms. The site also provides a number of tools for measuring Medicines Reconciliation including some performance measures and an improvement tracker tool which allows hospitals to create and chart their own performance measure results over time. IHI also has a mentor program for medication reconciliation. Organisations on the Mentor Hospital Registry volunteer to provide support, advice, clinical expertise, and tips to hospitals seeking help with their implementation efforts. NOTE: REGITRATION WITH ITE I REQUIERD Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 13

14 Medicines Use and afety Massachusetts Coalition for the Prevention of Medical Errors (UA) Handoffs (MATCH) Toolkit for Medicines Reconciliation (UA) Better Outcomes for Older adults through afe Transitions (BOOT) project website (UA) ucing_medication_errors.shtml als/quality-patientsafety/patient-safetyresources/resources/match/ma tch.pdf g/resourceroomredesign/rr _CareTransitions/html_CC/01 HowtoUse/00_Howtouse.cfm A range of materials available from the Reconciling Medications Collaborative ( ) a state wide patient safety initiative for Massachusetts hospitals to reduce medication errors by reconciling medicines. Materials developed as part of the collaborative include policies, staff education materials, examples of successful implementation strategies, implementation worksheets, guidelines for getting started, and references. A set of measurement protocols and accompanying excel spreadsheets for collecting data and generating graphs of the core evaluation measure Percent Medications Unreconciled are also available. This toolkit is based on the Medications at Transitions and Clinical Handoffs (MATCH) Web site. MATCH was developed by Gary Noskin, M.D., and Kristine Gleason, R.Ph., of Northwestern Memorial Hospital in Chicago, Illinois, through the support of Agency for Healthcare Research and Quality (AHRQ) Grant No. 5 U18 H and collaboration between Northwestern University Feinberg chool of Medicine and The Joint Commission. This toolkit incorporates the experiences and lessons learned by health care facilities that have implemented the MATCH strategies to improve their Medicines Reconciliation processes. The Better Outcomes for Older adults through afe Transitions (BOOT) initiative, organised by the ociety of Hospital Medicine in the U, provides resources to optimise the hospital discharge process. The resource room includes expert and evidence based interventions to promote a safe and high quality hospital discharge as patients transition out of the hospital setting. Although not specific to Medicines Reconciliation the Care Transitions implementation Guide provides valuable guidance on using quality improvement methodology in effecting changes in discharge practices in an organisation. NOTE: REGITRATION WITH ITE I REQUIERD Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 14

15 Medicines Use and afety National Institute for Health and Clinical Excellence (NICE) website (UK) e/index.jsp?action=byid&o= Provides details on the NICE patient safety guidance 1: Technical patient safety solutions for Medicines Reconciliation on admission of adults to hospital a policy which required all public hospitals in the UK and Wales to put in place formal systems for admission reconciliation by December As well as the guidance document the site provides an audit tool, PowerPoint presentation, costing tools and other useful information Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 15

16 Medicines Use and afety References: 1. National Institute for Health and Clinical Excellence (NICE) and the National Patient afety Agency (NPA). Technical patient safety solutions for Medicines Reconciliation on admission of adults to hospital. December 2007, available at: (Accessed 23rd eptember 2014) 2. National Institute for Health and Clinical Excellence (NICE). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. March 2015, available at: (Accessed 28th March 2015) 3. Rozich JD, Resar RK. Medication safety: One organization s approach to the challenge. JCOM. 2001;8(10): Kripalani, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297: Philbert I, Barach P. The European HANDOVER Project: a multi-nation program to improve transitions at the primary care inpatient interface BMJ Qual af 2012;21:i1 i6. doi: /bmjqs Council of Europe. Creation of a better medication safety culture in Europe: Building up safe medication practices. Expert Group on afe Medication Practices (P-P-PH/AFE), Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press; Bates DW, pell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA1997; 277: Rozich JD, Howard RJ, Justeson JM, et al. Patient safety standardization as a mechanism to improve safety in health care. J Qual af 2004; 30(1): Gleason KM, Groszek JM, ullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health yst Pharm 2004; 61: Dodds L. Results of a Collaborative Audit of Pharmacy-led Medicines Reconciliation (MR) in 56 trusts across E & E England. Medicines Use and afety Division, East and outh East pecialist Pharmacy ervices Available at (Accessed 23 rd eptember 2014) 12. Campbell F, Karnon J, Czoski-Murray C, Jones R. ystematic review for clinical and cost effectiveness of interventions in Medicines Reconciliation at the point of admission (2007). The University of heffield, chool of Health and Related Research. Available at (Accessed 14 th April 2015) 13. Dodds L. Which patients benefit most from Medicines Reconciliation? A collaborative evaluation of the outcomes of Pharmacy-led Medicines Reconciliation in various care areas. Available at Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 16

17 Medicines Use and afety safety/ervice-deliv-and-devel/meds-reconciliation/which-patients-benefit-most-from-medicinesreconciliation/?query=reconciliation&rank=81 (Accessed 14 th April 2015) 14. Karnon J, Campbell F, Czoski-Murray C. Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation). J Eval Clin Prac 2009; 15: Whittington J, Cohen H. OF Healthcare s journey in patient safety. Quality Management in Health Care. 2004;13(1): Michels RD, Meisel. Program using Pharmacy technicians to obtain medication histories. Am J Health-ys Pharm. October 1, 2003;60: Rozich JD, Resar RK, et al. tandardization as a mechanism to improve safety in health care: Impact of sliding scale insulin protocol and reconciliation of medications initiatives. Joint Commission Journal on Quality and afety. 2004;30(1): Murphy EM, Oxencis CJ, Klauck JA et al. Medicines Reconciliation at an academic medical centre: Implementation of a comprehensive program from admission to discharge. American Journal of Health-ystem Pharmacy. 2009;66(23): Maldonado AQ, Weeks DL, Bitterman AN et al. Changing transplant recipient education and inpatient transplant Pharmacy practices: A single-center perspective. Am J Health yst Pharm May 15; 70 (10): Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 17

18 Medicines Use and afety Chapter 2 Definition of Medicines Reconciliation and Process haring This chapter aims to share the different approaches that organisations have taken to implement Medicines Reconciliation. The chapter also attempts to define and standardise the concepts and definitions that underpin effective Medicines Reconciliation. 2.1 Medicines Reconciliation Definition and Guiding Principles There are several definitions of Medicines Reconciliation within the literature. Although the underlying principles within the different definitions tend to remain the same the varying definitions can cause some difficulties in the implementation, resource allocation and measurement of MR. Therefore clarifying the definition and the processes underpinning MR is critical to ensuring uniform approaches and measurements to MR are embedded within and across organisations. The Institute for Healthcare Improvement 1 define Medicines Reconciliation as the process of creating the most accurate list possible of all medications a patient is taking including drug name, dosage, frequency, and route and comparing that list against the physician s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital. A working definition developed by NH England Medication afety team that supports implementation of MR at a practical level in secondary care is described below (for the purposes of this best practice resource/toolkit the NH England definition of MR will be used) The collection and accurate identification of a patient s current list of medicines prior to hospital admission PLU the identification AND recording of any discrepancies compared with the list of medicines prescribed since the hospital admission. Resolution of any discrepancies identified should occur as soon as possible using clinical judgement to ensure safe and effective patient care The World Health Organisation 2 have developed several guiding principles that apply to Medicines Reconciliation implementation which are shown in table 2.1. Table 2.1: The World Health Organisation Guiding Principles on Medicines Reconciliation Guiding Principle 1: An up-to-date and accurate patient medication list is essential to ensure safe prescribing in any setting The development, maintenance and communication of a complete and accurate medication list throughout the continuum of care - whenever and wherever medications are used - is essential for reducing adverse medication events. Guiding Principle 2: A formal structured process for reconciling medications operates at all interfaces of care Having a structured process for reconciling medications at all points of transfer decreases the risk of communication errors and adverse medication outcomes. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 18

19 Medicines Use and afety Guiding Principle 3: Medicines Reconciliation on admission is the foundation for reconciliation throughout the episode of care The key to the success of Medicines Reconciliation at all interfaces is to first have a process working effectively at admission to the health care facility. Appropriate admission Medicines Reconciliation is the foundation to support and facilitate efficient and appropriate reconciliation at internal transfers and discharge. It should occur early in admission, preferably within 24 hours of admission. Guiding Principle 4: The process of Medicines Reconciliation is one of shared accountability with staff aware of their roles and responsibilities For Medicines Reconciliation to be effective staff need to be aware of their roles and responsibilities in the process so that patients have their medicines reconciled and discrepancies resolved early within their admission. Guiding Principle 5: Medicines Reconciliation is integrated into existing processes for medication management and patient flow Effective and efficient implementation of a Medicines Reconciliation process requires integration of its steps into existing hospital systems. Guiding Principle 6: Patients and families are involved in the Medicines Reconciliation Medicines Reconciliation is most effective when patients and families are engaged in the process. Guiding Principle 7: taff responsible for reconciling medications are trained to take a best possible medication history (BPMH) and reconcile taff responsible for obtaining and recording the BPMH and reconcile medications should have the knowledge, skills and attitudes necessary to safely perform the tasks. 2.2 Process of Undertaking Medicines Reconciliation The National Prescribing Centre (NPC) Guidance Medicines Reconciliation published in 2007 is the key national document that supported the implementation of MR following the NICE guidance issued in In addition The East and outh East pecialist Pharmacy ervice template policy for Medicines Reconciliation published in 2009 was also a key tool that NH organisations especially in the East and outh East of England used to implement MR processes. However, these two key documents used slightly different terminologies in describing the processes through which MR should be undertaken. For example the NPC document used descriptors such as tage 1, tage 2, Basic and Full reconciliation whereas the East and outh East pecialist Pharmacy ervice template policy used descriptors such as Level 1, Level 2, Admission Led and Pharmacy consolidation. Through consultation with the members of the working group that supported the development of this best practice resource/toolkit a consensus agreement was reached that indicated that the terms tage 1, Basic, Level 1, and Admission Led are relatively synonymous with each other as are Full, tage 2, Level 2 and Pharmacy consolidation. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 19

20 Medicines Use and afety tage 1 = Basic = Level 1 = Admission Led Medicines Reconciliation tage 2 = Full = Level 2 = Pharmacy Consolidation Essentially can be described as obtaining a medication list Drug History on admission at the clerking in stage by the admitting clinician which is then documented onto the drug chart. In the majority of scenarios the admitting clinician undertaking this drug history will be the admitting Dr or Nurse who has triaged the patient. Essentially includes Pharmacy staff involvement (Pharmacists and/or Pharmacy Technicians) by where the Pharmacy staffs verify the most accurate medication list for that patient using two or more sources. It also involves identifying any discrepancies (intentional or unintentional) between the Pharmacy verified list and the medication list charted by the admitting clinician onto the drug chart and then resolving the identified discrepancies accordingly. tage 2/Level 2 MR should be conducted by suitably trained Pharmacists or Pharmacy Technicians (for example of training programmes and competency assurance please see chapter 5) It is important to recognise that tage 2/Level 2 MR does not encompass pharmaceutical review clinical screen medication review of the prescription. This must be conducted by the Pharmacist and is outside the scope of this best practice resource/toolkit. This best practice resource/toolkit although generally aimed at Pharmacy staff conducting Medicines Reconciliation can be used and adapted for use with other healthcare professionals involved in the MR process. For example in order to improve the quality of stage1/level1 MR clinicians involved in admitting patients should be a targeted for training and competency assessment as a priority as it would improve efficiency, patient safety and reduce the risk of ADE. The detailed process involved in conducting a MR is well described in the literature with individual organisations usually having their own local policies and processes. The underlying principles of Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 20

21 Medicines Use and afety conducting effective MR are articulated in the National Prescribing Centre (NPC) guidance Medicines Reconciliation: A guide to implementation published in 2007 and is displayed below: The Medicines Reconciliation process in detail: A useful way of remembering the steps in the reconciliation process is to adopt the 3Cs approach. Collecting Checking Communicating Collecting: The collecting step involves taking a medication history and collecting other relevant information about the patient s medicines. The information may come from a range of different sources (some potentially more reliable than others). Checking: The checking step involves ensuring that the medicines and doses that are now prescribed for the patient are correct. Obviously, this does not mean that they will be identical to those documented during the basic reconciliation process. For example, a doctor now responsible for the patient may make some intentional changes to their medicines but any discrepancies will need to be resolved in the final step of the process. Communicating: Communicating is the final step in the process, where any changes that have been made to the patient s prescription are documented and dated, ready to be communicated to the next person responsible for the medicines management care of that patient. Below is a flow chart published by the National Prescribing Centre that details the steps involved in the MR process (The original flow chart in better resolution can be viewed via 0Process%20of%20Meds%20Rec_May%2015.pdf). The flow chart is a useful tool that can be used and adapted by Pharmacy teams who may wish to conduct a process mapping exercise of the MR to identify any risks or quality improvement initiatives or/and to engage wider multidisciplinary and management teams. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 21

22 Medicines Use and afety Fig 2.2.1: A flow chart of the Medicines Reconciliation process of patient admission from primary care to secondary care Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 22

23 Medicines Use and afety Fig 2.2.2: A flow chart of the Medicines Reconciliation process of patient discharge from secondary care to primary care Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 23

24 Medicines Use and afety 2.3 haring of Medicines Reconciliation Processes, Practices and Documents everal NH organisations have kindly shared their Medicines Reconciliation Processes, Practices and Documents so that organisations can look at different examples and think about what could be incorporated into their own policies and practices to optimise the MR process. The table below provide examples of drug chart documentation and methods of MR documentation & policy examples. Table 2.3.1: Examples of drug chart documentation of Medicines Reconciliation Organisation Contact Brief description & comments from contributor about use Resources Hinchingbrooke Rachel Waldon Drug history documentation goes on the front page of the drug chart. HH First page drug Health Care NH Trust All MR record keeping is on the drug chart. Each drug on the internal sections is marked in the Pharmacy box (Hx) with dose details and cross referenced to the list on the front for discrepancies chart Advantages: Remains with patient / subsequently filed in notes / can easily be transcribed to HH OP for MR subsequent charts when rewritten / easy to transcribe changes onto GP discharge letter (Extract) Disadvantages: May be reviewed by a Dr when written by a technician & not validated by a Pharmacist. This could mean that discrepancies noted are not correct. Discrepancy Resolution: Policy states how this should be managed. The advantage is it is easy to track management of unintentional discrepancies; the disadvantage is that it relies on staff experience to assess the severity of the problem Imperial College Gavin Miller The advantage of a specific MR section on the drug chart is that the information is readily available IH MR section of Healthcare NH Trust Gavin.miller@imperi al.nhs.uk when the chart is screened at discharge. A disadvantage is that every time the drug chart needs rewriting, the information needs to be transferred (every 2 weeks) drug chart Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 24

25 Medicines Use and afety Medway NH Elizabeth Pearce Within the drug chart the back page is used as a prompt for MR. The back page requires completing MM MR section of Foundation Trust Elizabeth.Pearce@m and signing before a MR is seen as completed for the patient. Drug chart edway.nhs.uk North West Mira Jivraj There is a section on the front of the drug chart for the drug history. The MR process is supported NWLH Drug Chart London Hospitals NH Trust Mira.Jivraj@nhs.net by a clinical induction pack and training and new starters must complete an accreditation before delivering MR Table 2.3.2: Other methods of MR documentation & policy examples Organisation Contact Brief description and comments about use Resources Barts Health Jayne Yeung A ward planner is used to manage workload and helps the team prioritise workload in order to BH Ward planner NH Trust Jayne.Yeung@barts undertake Medicines Reconciliation in a timely manner. health.nhs.uk The ECAM (Emergency Care and Acute Medicine) team are trained in how to use the ward planner and undertake OCEs to demonstrate they can use it effectively. The ECAM Pharmacists also BH Ward planner OP undertake an assessment on how to undertake 'Medicines Reconciliation on Admission' and an assessment on how to undertake 'Medicines Reconciliation on Discharge' to ensure medication discrepancies are identified appropriately. Medicines Reconciliations are communicated to the doctors in a timely manner either verbally (if urgent) or via the 'ECAM doctor's job list communication sheet' (if non-urgent) for patients on admissions. Any medication discrepancies identified on discharge are amended appropriately on the Discharge TTA prescription. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 25

26 Medicines Use and afety Chesterfield Andrew hardy All emergency admissions have their medical clerking written on to a pro-forma. There is a page for CR Clerking pro- Royal Hospital NH Foundation A.Hardy2@nhs.net documenting medicines on admission (attached) within the pro-forma. When Pharmacy staffs undertake Medicines Reconciliation they may find unintentional discrepancies. If these can be forma Trust resolved by a prescribing Pharmacist the amendments are made immediately onto the medicines (Electronic ystem) page of the clerking pro-forma (rather than making an entry into the later chronological paperwork). This new information is on the right hand side and signed for so it is clear who has added the information and when. If the Pharmacist is unable to resolve the discrepancy immediately or in face to face discussion then an entry is made in the chronological notes so it will be seen and acted upon. The advantage of using the pro-forma is that it is quicker to document changes and it is easy to refer back to admission medication. Pharmacy documentation of admission medication is in the form of a free text note linked to the electronic prescription; this is updated during the admission to note the changes to medication and reasons for those changes. This note is then used at discharge to ensure the information is communicated on the discharge summary. The disadvantage is that this is time consuming and the quality of the note varies considerably. East ussex Alan Hopkins A set template is used to complete MR that can be uses with handheld tablet devices. This allows EH Tablet form Healthcare NH Trust (Electronic ystem) Alan.Hopkins@esht. nhs.uk the completion of the forms on the ward (either at the nurse s station or bedside). The form encompasses medication on admission, additional medication, community Pharmacy services used and compliance. Because the form is electronic it can be accessed anytime and saved so it can follow the patient around the hospital during their stay e.g. patient admitted to MAU and had an MR, then the electronic entry will be saved under the ward folder and transfer to different wards as and when required. The disadvantage with the system is the need for printing and filing hard copies in Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 26

27 Medicines Use and afety the notes. ometimes they get lost, misfiled by other healthcare professionals, or overlooked because it has no set place within the notes. Next steps: To integrate this form into the Patient Documentation Booklet. This is used for every hospital admission and will ensure all health care professionals know where to find MR information and will support discrepancy resolution. East London Alan Cottney A MR form is used. Advantages are: EL MR form NH Foundation Trust Alan.Cottney@eastl ondon.nhs.uk Word format, so can be completed electronically- makes MR clear and easy to read, easy to add rows if more space is required. Can be printed off and inserted in patients notes, or attached to electronic notes. EL Fax form Useful as a prompt: reminds to use more than one source for MR, reminds to ask about compliance aid. Contains space for documenting any discussion that occurred with the patient, and for highlighting discrepancies. When filed in notes can help provide clear audit trail, and a reference for future use. Disadvantages are: Filed in notes, so no information about MR actually present on drug chart. A Fax drug history form is also used. There are some advantages we have found with this version: Clearly asks for a clinical summary - which can help to identify why certain medication is prescribed - thus potentially sparing another phone call to the GP. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 27

28 Medicines Use and afety Also clearly asks for allergy information and whether or not the patient is on a compliance aid - so helps to ensure we get all necessary information first time round. As the document is in Word format it can be completed electronically, and faxed from NH Mail account - making the process quicker and reducing paper burden. Peterborough Meb Walji The MR policy has information in the appendix on how to approach a MR consultation and also how P MR policy and tamford Hospitals NH Foundation Meb.Walji@pbhtr.nhs.uk to document information. Trust Oxleas NH Carol Paton Oxleas NH Trust has determined that MR responsibilities lie with the admitting doctor. The OX MR policy Foundation Trust Carol.Paton@oxleas.nhs.uk Pharmacist provides a second check that MR has taken place within one week of admission when any discrepancies which look to be unintentional will be recorded. It was decided that taking the responsibility for MR away from doctors was deskilling them. Regular audit is used to demonstrate effectiveness of this approach. herwood Cath Fletcher The medication history is documented in the appropriate section of the patients medical clerking. F Drug Chart Forest Hospitals NH Foundation Trust Catherine.Fletcher@ sfh-tr.nhs.uk MR info is also documented on the drug chart in dedicated box(es) on the front with sources used. If only one source has been obtained the notes are annotated 2 nd so it is clear that a second source should be obtained if possible. Changes made on admission e.g. medication on hold, dose F OP for MR changes etc. are also documented on the front of the drug chart. If an MMT does the DH and there are discrepancies they write see clerking on the front of the drug chart so the Pharmacist knows there are issues to be resolved. The Pharmacist ticks the box, initials and dates once these are F Enabling policy resolved. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 28

29 Medicines Use and afety Pharmacy annotate all prescriptions inside the chart with either DH or new to assist medical staff with informing GPs of medication changes on discharge. Also annotate with or dose on DH items where doses have been changed. This also helps to ensure appropriate transfer of info to GPs on discharge. Pharmacy patient profiles which are completed at the point of admission also have a tick box to confirm when MR is complete. Discrepancy resolution: A trust Enabling Policy is in place which allows Pharmacists to write up items such as eye drops, creams, salbutamol inhaler, GTN spray etc without the need for them to be prescribed. The trust approves this and it has been found to be very helpful for items which Drs do not see as a priority to prescribe. University Hospitals of Leicester NH Trust Hannah Kooner Hannah.Kooner@uh l-tr.nhs.uk Oncology and Haematology wards currently using electronic prescribing- Medchart. All Medicines Reconciliation information is added to EPMA only. No documentation in the notes is needed. Pharmacists will document in the medical notes if changes not actioned from EPMA. Catherine Loughran Advantages: All information can be viewed at all times. Previous admissions are easily accessible if needed. Clear comment can be viewed. Discrepancies easily documented Electronic handover is used as form of communication and follow up tool. Can be accessed anywhere by multiple members of the team- NO sharing of a paper handover. Clear and timely. Disadvantages: Can be time consuming. ome duplication with documentation on EPMA. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 29

30 Medicines Use and afety Discrepancy resolution: When discrepancies occur between the MR and the electronic chart, medications are added to the medications on admission page and an alert is added to the patients chart. This alert will appear each time a Pharmacist or doctor accesses the chart until this alert has been cancelled. This also acts as a reminder for the Pharmacist to follow the issue up if still needed. East Lancashire Alistair Gray Overview: A checklist approach has been developed and evolved to support the Medicines Medicines Hospitals NH Alistair.gray@elht.nh Reconciliation process by the Pharmacy team. A printed checklist is inserted into the patient notes Reconciliation Trust s.uk at the beginning of the Meds Rec process which prompts the capture of the right information in a Checklist: logical order to ensure that an accurate, complete and informative drug history is obtained. The checklist contains prompts to refer the patient to other health professional e.g. anticoagulant team, resources.nhs.uk/upl diabetic specialist nurse and acute oncology team when appropriate (NB: an e-patient tracking oad/documents/com system which facilitates referral to other health professionals). munities/p_e_e Pharmacists and Pharmacy technicians are also competency assessed prior to conducting Medicines Reconciliations; the checklist helps maintain their competencies. In addition changes to prescription stationery complements the MR process making it easy to identify what medicines the patient has come in on, what has started, stopped, changed and why. _England/East%20L ancashire%20med% 20Rec%20Checklist_ May%2015.pdf Outcomes: Although not formally audited the checklist intervention and changes in drug chart stationary has noticeably improved the quality and consistency of information captured during the MR process compared to pre-introduction of the checklist. It has also improved the quality of information contained within the discharge letter benefitting transfer of care. creening a TTA is a lot more quicker/easier when a patient has been through this checklist process and there is a lot more confidence in the information contained within the discharge letter (the e-discharge letter Example of Drug Chart and Discharge tationary: resources.nhs.uk/upl oad/documents/com munities/p_e_e Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 30

31 Medicines Use and afety includes a dropdown list to indicate if the drug history has been formally checked or not by a Pharmacist). _England/East%20L ancashire%20drug% 20Chart%20and%20 Discharge%20tatio nary_may%2015.pdf Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 31

32 Medicines Use and afety 2.4 ummary Care Records The availability of summary care records (CR) has significantly improved the efficiency and accuracy of the MR process. The CR is a live feed of the General Practitioner s patient medical records, the core record contains: Acute medications prescribed in the last 12 months Current repeat medications Repeat medications stopped in the last 6 months Allergies Adverse Drug Reactions The CR is a national (NH England) solution available 24 hours a day, 365 days a year and can only be accessed via a NH smartcard with access being completely auditable. The availability of CR within secondary care is a patient safety measure on the NH England Medicines Optimisation Dashboard. An example of a CR record (Fig 2.4.1) and a case study (Fig 2.4.2) demonstrating its use in hospital Pharmacy is displayed below: Fig 2.4.1: An example of a CR record Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 32

33 Medicines Use and afety Fig 2.4.2: CR use in hospital case study Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 33

34 Medicines Use and afety Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 34

35 Medicines Use and afety For further information regarding implementing the contact details of the regional implementation teams are detailed below. They can also offer practical advice and support, including step-by-step guides, training and engagement materials, alongside other useful resources. North: Midlands: East: London: outh: References: 1. Institute for Healthcare Improvement (IHI) Webpage. Available at (Accessed 20th Nov 2014) 2. World Health Organisation (WHO). Assuring medication accuracy at transitions in care: Medication Reconciliation. Available at (Accessed 4 th April 2015) Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 35

36 Medicines Use and afety Chapter 3 Best Practice tandards This chapter aims to set out the best practice standards that should be observed when conducting robust Medicines Reconciliation. The best practice standards were developed by the MR working group through a consensus approach. There are 88 individual best practice standards that have been grouped into 6 overarching standards which have been further separated into 3 main themes based on the process of conducting a Medicines Reconciliation. These standards aim to support and enable individuals and organisations to improve the quality of Medicines Reconciliation. The standards although predominantly applicable to secondary care providers are transferable to other care settings (e.g. primary and community care) and should be used to develop best practice. It should also be noted these standards are equally applicable to the paediatric population. Theme: Timing of Medicines Reconciliation tandard 1 Timing of Medicines Reconciliation on Admission Much of the guidance centred on Medicines Reconciliation for example the NICE Medicines Optimisation Guidance 1, the RP Professional tandards for Hospital Pharmacy 2 and the World Health Organisation 3 guidance indicates that MR should be carried out within 24 hours of admission to a hospital setting. Within this toolkit and in line with the standards set by NH England in its medication safety thermometer, this guidance is pragmatically interpreted as standard 1.1 set out below. In terms of best practice this standard is applicable to all hospital settings and care areas, however, it is acknowledged that in certain settings or care areas e.g. Community Hospitals, Mental Health, Maternity, Day urgery a limited clinical Pharmacy service may be in operation and that this standard may not be achievable in these scenarios enior Pharmacy Managers should undertake a risk assessment and set safe local standards, have mitigation strategies in place and/or document the risk on the trust risk register. tandard 1.1 Ensure that patients receive a MR by a member of the Pharmacy team the day of, or the day following, admission. Helpful Hints / Comments It is appreciated that it may be difficult to adhere to the standard where patients are admitted over a weekend period (e.g.friday through to unday) however, all patients should receive the same level of care irrespective of when they are admitted in line with the 7 day working agenda Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 36

37 Medicines Use and afety A member of the Pharmacy team simply requesting a patient s medication list from the GP does NOT meet the MR definition unless any discrepancies have been identified AND recorded (i.e. within the clinical notes and /or on the prescription chart) For the standard to be met all of the discrepancies identified DO NOT need to have been fully resolved (Resolution of any discrepancies identified should however occur as soon as possible using clinical judgement to ensure safe and effective patient care) This measure should be fed into the NH Medication afety Thermometer which is subsequently fed in the NH Medicines Optimisation Dashboard. The MO Dashboard can be viewed at Theme: Collection and Checking of Medicines Related Information tandard 2 Patient Consultation Consultation skills are of paramount importance during the Medicines Reconciliation process. The RP Professional tandard 1.1 for Hospital Pharmacy ervices 2 states that communication with, and involvement of, patients and carers is an integral component of safe, effective Pharmacy services, therefore unless it is not physically possible (eg, the patient is unconscious or confused) the patient should always be consulted as part of the MR process since they are the ones taking the medicines. The table below outlines the standards required when Pharmacy professionals undertake a consultation with a patient when conducting a Medicines Reconciliation. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 37

38 Medicines Use and afety tandards tructure of the Consultation 2.1 Ensure that the consultation is undertaken in a supportive environment, taking account of safety, comfort, confidentiality, dignity and respect 2.2 Ensure an introduction takes place and includes name and job role and purpose of the consultation 2.3 Ensure that the patient s identity is confirmed using at least two parameters e.g. name and date of birth 2.4 Ensure the patient has cognition and capacity 2.5 If there are language difficulties consider using NH Translation ervices or other appropriate services available within the organisation 2.6 Ensure that both open and closed questions are used to elicit a full list of the patient s medication regime 2.7 Ensure the discussion includes questions about how the patient manages their medication in their own home or care setting 2.8 Confirm adherence to medication regime and establish if the patient has difficulty with adhering to the prescribed medication regime e.g. missed dose(s) of treatment with reasons Consultation kills and Behaviours 2.9 Ensure that the scene for the consultation is set professionally and appropriately while building rapport with the patient 2.10 Ensure and acknowledge the patient s agenda without interrupting and further balance with your own agenda before negotiating a shared agenda Helpful Hints / Comments For example whether they have a medication compliance aid or help from relatives or carers. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 38

39 Medicines Use and afety 2.11 Communicate positively and effectively throughout the session, using language that is appropriate and respectful to the patient 2.12 Ensure that information is shared and discuss options in an open, honest and unbiased manner to support the patient in assessing the risks versus benefits in relation to medicines-taking and making changes to lifestyle 2.13 Ensure that communication and consultation skills are adapted to meet the needs of different patients 2.14 Recognise that patients are diverse; that their behaviour, values and attitudes vary as individuals and with age, gender, ethnicity and social background, and that you should not discriminate against people because of those differences 2.15 Ensure that respect for the patient s perception is considered and support the patient in selfexpression Consider the use of prompting tools to facilitate the consultation (such as checklists) in such a manner that it does not detract from the patient focus of the consultation 2.17 Ensure that questioning techniques utilise active listening to draw out the information needed to gain maximum benefit from the discussion and challenge the patient at a level which is appropriate for them 2.18 Ensure that patient understanding is checked at points within the consultation while allowing the patient time and space to reflect Example Questions/Prompts What medications do you take every day? Are there any medicines that you take less frequently e.g weekly or monthly medicines or medicines just when you need them? Using non-technical, non-jargon language has the greatest positive impact on the patient Patient s may not have English as their first language or some patients may have capacity, physical or sensory impairments ee East Lancashire Hospitals NH Trust Checklist in Chapter 2 Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 39

40 Do you use any eye drops, ear drops, inhalers, creams, ointments etc? Have you recently taken any antibiotics within the last 2-3 weeks? Is there anything else you take that has not been mentioned? Do you have any allergies to medications? Do you take any over-the-counter medicines? Do you take any multivitamins or herbal supplements? Are you wearing any medication patches? What happens when you take this medication? Medicines Use and afety Ask (where appropriate) if the patient uses any of the following? If on warfarin where is the yellow book? If diabetic and on insulin check insulin device and insulin passport Other monitoring booklets e.g. DMARD, Chemo Once weekly medication (state day of week) Home Oxygen Over the counter remedies, herbal, sourced from the internet, recreational tandard 3 ources of Information everal sources of information are available to help obtain an accurate medication history, none of which are 100% reliable. Therefore it is often necessary to use more than one source to confirm the medication history. On occasions one source of information may be sufficient, eg, it would be unnecessary to contact a GP surgery when an otherwise healthy patient says they do not take any medicines. The table below lists the possible sources of information, the standards that should be applied when using the information sources with some helpful hints and limitations to be mindful of. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 40

41 Medicines Use and afety Information ource All information sources The patient or person(s) managing the medicines tandards 3.1 The medication history should be collected from the most recent, accurate and reliable sources. Information should be cross-checked and verified using, if possible, a minimum of two sources. If sources conflict, use a third source or the patient to consolidate if appropriate. 3.2 Ensure where possible the patient or person(s) managing the medicines is one of the sources of information 3.3 Ensure the patient has cognition and capacity. If there are translation difficulties consider utilising NH translation services. 3.4 Ensure that the patient is asked regarding medicines such as inhalers, nebulisers, recent antibiotics, steroids, weekly meds, eye drops, patches, emergency use drugs etc. 3.5 Ensure that the patient is asked regarding recently started/ stopped medicines and Helpful Hints / Comments Any information that is to be followed up must be documented on the drug chart. For example; waiting for GP fax 01/01/ :30am or confirm with patient when at bedside 01/01/ :30am. On paper charts, a text box could be constructed to indicate the task is pending and then ticked and signed once completed. Consider the accuracy and limitations of each source before making a clinical judgment. It is good practice to place a hardcopy (if available) of the information sources within the medical notes for record purposes. Check with the patient first if they manage their own medicines and if they take their medicines as on the information source e.g. the patients own drugs (PODs)/Repeat slip/gp record etc. If it is not the patient managing the medicines consider liaising with the family member, carer, care home staff, district Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 41

42 Medicines Use and afety recent changes in doses. nurse etc. If the patient is temporarily unable to confirm the medication history for example due to confusion, document this so that other members of staff are aware and leave a prompt to try again sometime later when the condition may have improved. This is important as medicines are not always taken as prescribed. Check for any hand held medicines related documents (e.g. methotrexate book, warfarin book, Insulin passport, My Medication Passport, medicine/healthcare apps) Repeat 3.6 Ensure that all the pages of the repeat tear-off slips are available and checked Limitations of a repeat prescription tear off prescription 3.7 Confirm details with the patient or person(s) managing the medicines to ensure it slips: tear-off slips. is current Does not include information on acute 3.8 Check the dates when the prescriptions were last issued prescriptions Prescription may not have been collected/ dispensed/ taken ome medicines may have stopped recently Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 42

43 Medicines Use and afety Requesting 3.9 Obtain and document consent from the patient to contact the GP for information Use discretion on the need to contact the information unless the patient is unable to give consent GP if the information required is minimal from the GP 3.10 Confirm the name and designation of the person providing the information from such as to confirm no medication the GP practice Information provided by the GP has 3.11 Obtain a print out from the GP system via a fax or as opposed to verbal several limitations such as it will or may not communication. If possible, request a standard report from GPs regarding include: medication (the GP systems have this functionality). This approach will support o OTC medicines or requesting and sending essential information easier and more efficient o Hospital supplied medication 3.12 Ensure GP information is as complete and current as possible and includes: o Medication supplied via homecare Details of any acute prescriptions issued in the last 3 months o Medication prescribed by a Dental Regular, on-going treatment including repeat prescriptions practitioner Allergy status o Medication prescribed by an It may be necessary (use clinical judgment) to request the last five urgent care centre, walk in centre, consultations the patient has had with the GP and past medical history as it Hospital at Home team, specialist may help in revealing recent medication changes nurse prescribers, GUM/HIV medicines If using a standard report it should contain repeat medication, acute medication issues, allergies and display when medicines were last issued along with quantities. A template report set up in ystem One prescribing system has been demonstrated to work well in Bedfordshire Fax or communication is preferred Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 43

44 Medicines Use and afety to reduce the risk of any errors as a result of miscommunication or omission of important information If ing ensure it is from and to an encrypted central mailbox e.g. nhs.net If faxing ensure that only staff have access to the fax machine and adhere to any local policies that may be in place regarding faxing confidential and patient related information. Check the dates of issue and quantities of medicines issued as these may highlight adherence issues or if a medicine is no longer being taken Only viewing the repeat medication is often insufficient as the patient may have been issued an acute prescription recently e.g. An antibiotic for a chest infection that has then not resolved and resulted in the hospital admission ome GP systems may remove items from repeat list if not issued frequently In addition GPs may not make an item available on repeat for a number of Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 44

45 Medicines Use and afety reasons o newly started and the GP wishes to monitor patient response after each prescription o the GP may want to remain in control of quantities issued o the GP may have just forgotten/ not yet had time to move item to repeat o the medicine may have been initiated elsewhere but GP may not yet have received / actioned letter containing full directions on continuing therapy Recently amended/started/stopped medication may well have contributed to the reason for admission so this may affect the decision to amend/withhold/restart medicines on admission. This information may be in the acute prescriptions section or within the GP consultation section Verbal requests to patients by the GP to omit or change medication and/or Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 45

46 Medicines Use and afety handwritten prescriptions may not appear on the prescription record unless a prescription is issued. The outcome of a telephone appointment or home visit with regards to medicine changes is usually documented in the consultations section. This information would otherwise be missed and may help the Pharmacy team to understand the intention of the GP and/or explain why the patient may not be taking their medicine as prescribed. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 46

47 Medicines Use and afety ummary 3.13 Ensure that staff members that utilise CR and have undertaken the relevant face The CR does not always state the last Care Records to face or elearning training available on the use of CR date the prescription was issued 3.14 Obtain and document patient consent prior to accessing CR (check local policy ometimes states Date prescribed which and guidance) could be some time ago therefore clarify if 3.15 Check the date the record was updated (should be updated daily) patient is still taking Print off the information and place in the patient s notes Recent Hospital Discharge Notifications Hospital Transfer Letters 3.17 Ensure that hospital discharge is recent (use clinical judgement) It is important to be mindful that the GP 3.18 Confirm details with patient/carer to identify any further clinically relevant changes since discharge may not have updated the patient records or possibly actioned the discharge notification changes It is important not to assume that the discharge notification is accurate as if a thorough MR was not conducted at the admission within that episode of care the discharge notification may be inaccurate 3.19 Ensure that a copy of the drug chart in use prior to transfer is faxed across This will allow an appreciation of what medication the patient has been administered in the preceding days and weeks, it may also provide information on the MR conducted on admission and any pharmaceutical interventions made If no MR was completed or unclear, there may be a need to undertake a full MR and Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 47

48 Medicines Use and afety document which medicines were taken prior to initial hospital admission and which medicines have been started at the transferring hospital. This is important as all changes must be communicated to the GP upon discharge Patients Own 3.20 Ensure that if a POD OP is in place and it is being followed Be vigilant for dispensing errors Drugs (POD) 3.21 Ensure that all PODs are assessed Confirm that patients can take their 3.22 Where possible ensure that each POD is confirmed with the patient or person(s) medicines or are taking as labelled. managing the medicines Confirm the doses being taken as they may have been changed but not yet reflected on current supply Check for additional medicines not listed on sources checked for example hospital only medicines, homecare medicines etc. Check for CDs, fridge / bulky items as these may not be brought in or the nurse may already have locked away Check for medicines that the patient may keep on their person e.g. topical preparations, inhalers ome PODs may no longer be current, may be recently stopped, may be a family members medicines or a dispensing error Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 48

49 Medicines Use and afety 3.23 Ensure PODs are suitable for use, check local POD OP an example criteria is detailed below: o PODs must be clearly labelled with the patient s name o PODs that are dispensed must have printed directions on the pack o Ensure that the packaging corresponds to the content and that the description of the product or Pharmacy label matches the contents o If not in original (manufacturer s) container, it is possible to identify the product o Check the patient is able to use any medication devices correctly e.g. Inhalers o Confirm the identity of any medicines supplied in a compliance aid and whether there are any medicines that are not in the compliance aid e.g. PRN medicines, liquid medicines o Confirm any discrepancies with the dispensing Community Pharmacy Be mindful that the patient may have only brought blister strips with no container or label OTC, GL products, inhalers, insulin, GTN spray etc. may not be labelled. Ensure that the medicines belong to the patient and attach name label if not labelled. If dispensed more than 6 months ago, check for potential non adherence to the medication regime Confirm the medicine has been prescribed for the patient prior to admission. Nursing or 3.24 Ensure that all the pages of the MAR chart are available Check for any potential transcription care home 3.25 Check with the patient or care home staff when the last PRN medications were errors Medication taken if relevant Printed charts from community administration record (MAR) charts. Pharmacies maybe more accurate, however be mindful of medicines that may not be documented on the MAR chart for example if a recent hospital discharge has taken place or an acute prescription has been supplied Community 3.26 If possible obtain consent from the patient to call the community Pharmacist Be mindful that the patient may use more Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 49

50 Medicines Use and afety Pharmacist Confirm and document name and designation of the person providing the information Notify the community Pharmacist when a patient using a MCA is admitted and discharged Ensure that upon discharge all medication changes are communicated than one community Pharmacy therefore a complete medication history may not be available MCAs are usually dispensed as repeat prescriptions and community Pharmacies may attempt to deliver ongoing supplies whilst a patient is in hospital if not notified of their admission. Upon discharge, community Pharmacies will often arrange collection of MCAs from a patients home if they have not been taken into hospital and are no longer required tandard 4 Identification and Resolution of Discrepancies Resolution of any medication related discrepancies identified is the CRITICAL outcome of the MR process that supports patient safety and good quality care, therefore processes must be in place to ensure that discrepancies are resolved in a timely manner. Discrepancies may be intentional or unintentional. Intentional discrepancies can be defined as any difference between the medicines the patient was taking prior to admission and the medicines prescribed in their new care setting that have been changed intentionally and agreed with the clinician(s) responsible for the patient's care. Unintentional discrepancies (errors, omissions or unintentional additions) can be defined as any difference between the medicines the patient was taking prior to admission and the medicines prescribed in their new care setting that is not a conscious change. The table below sets out standards that must be adhered to when identifying and resolving any medication related discrepancy. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 50

51 Medicines Use and afety tandards 4.1 Ensure that any medicines related discrepancy is documented on the drug chart/medical notes/electronic prescribing system/other process for the prescribing team to review. The discrepancy must be REOLVED in a timely manner using clinical judgement. Helpful Hints / Comments Clinical judgement should be used in assessing the urgency of resolving the discrepancy for example omission of a critical medicines would necessitate contacting the clinicians immediately Clear documentation and timely resolution of unintentional discrepancies should become key outcomes for Pharmacy-led MR. Failure to address these issues may undermine the patient safety benefits of this service. 4.2 Ensure that any intention to omit a medicine is recorded clearly and unambiguously on the drug chart/medical notes/electronic prescribing system/other process. The reason for omitting the medicines must be clearly documented. 4.3 Ensure that any discontinuation of a medicine is recorded clearly and unambiguously on the drug chart/medical notes/electronic prescribing system/other process. The reason for discontinuing the medicines must be clearly documented. 4.4 Ensure that any commencement of a new medicine is recorded clearly and unambiguously on the drug chart/medical notes/electronic prescribing system/other process. The reason for starting the new medicine must be clearly documented. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 51

52 Medicines Use and afety 4.5 Ensure that any change in dosing of a medicine is recorded clearly and unambiguously on the drug chart/medical notes/electronic prescribing system/other process. The reason for the changing the dose of the medicine must be clearly documented. 4.6 Ensure that any changes in formulation of a medicine are recorded clearly and unambiguously on the drug chart/medical notes/electronic prescribing system/other process. The reason for the change in formulation of the medicine must be clearly documented. e.g. gliclazide dose reduced due to low BMs, from 80mg BD to 40mg BD. e.g. medicines converted to liquids whilst the patient has NG tube in place. 4.7 Ensure that changes in medicines due to local formulary restrictions are recorded clearly and unambiguously on the drug chart/medical notes/electronic prescribing system/other process with detail of the original medicine. Theme: Communication and Documentation of Medicines Reconciliation tandard 5 - Documentation of Medicines Reconciliation at Admission The documentation of the Medicines Reconciliation is an integral part of the MR process as it allows all healthcare professionals to view the changes to the patient s medication regime and also allows the final discharge summary to be an accurate list of medications that can be communicated to the next caregiver. The table below details the standards required when documenting the MR at admission. tandards Helpful Hints / Comments 5.1 Ensure that all written documentation is legible, clear and in indelible ink or electronic 5.2 Ensure that all allergies or lack of allergies to medicines (NKDA) are clearly documented including the causative medication and brief description of reaction/outcome 5.3 Ensure that generic drug names are used in all documentation unless otherwise specified for example when brand names are required for bioavailability issues Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 52

53 Medicines Use and afety 5.4 Ensure that the patient s medication regime prior to admission is clearly recorded and documented on the appropriate section of the drug chart/medical notes/ electronic prescribing system or other process 5.5 Ensure that the dose of each medicine is clearly recorded and documented in the correct units e.g. mg or micrograms. 5.6 Ensure that the strength of the preparation is clearly recorded and documented for any liquid formulations e.g. 1mg/ml. 5.7 Ensure that the formulation of each medicine is clearly recorded and documented e.g. tablets. 5.8 Ensure that the frequency of each medicine is clearly recorded and documented Latin abbreviations are acceptable e.g. OD, TD 5.9 Ensure that the route of administration is clearly recorded and documented for each medicine. Latin abbreviations are acceptable e.g. PO, PR Where the medicine is clearly for oral use e.g. tablets this does not need to be expressed unless there is risk of ambiguity Ensure that instructions on how to use the medicines are explicitly documented to prevent any confusion or ambiguity when medicines are prescribed For example The timing of doses are clearly documented where this is significant, e.g. steroids, Parkinson s Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 53

54 Medicines Use and afety 5.11 Ensure any recent changes (within 1-2 months) to the patient s medication regime is clearly recorded and documented as part of the MR 5.12 Ensure that the sources used for conducting the MR are clearly recorded and documented medicines, day of week for weekly preparations For inhaled preparations the strength and device is clearly documented For topical preparations that the site of application is clearly documented For insulin preparations, the brand, formulation, and type of device that the patient normally uses is clearly documented For hospital-only or homecare medicines the name of the supplier is clearly documented For high-risk medicines such as warfarin or methotrexate any additional information is clearly documented Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 54

55 Medicines Use and afety 5.13 Ensure that any adherence issues identified during the MR process are clearly recorded and documented with actions taken to resolve the issues 5.14 Ensure that the name and contact details of the person conducting the MR is clearly recorded and documented along with the date. tandard 6 - Documentation of Medicines Reconciliation at Discharge Ensuring that all the all necessary information about the patient s medicines is accurately documented and communicated to the next healthcare provider is vital to support safe transfer of care. The Institute of Health Improvement suggested that poor information communication on discharge is responsible for over 50% of all medication errors and up to 20% of adverse events 4. The RP Professional tandard 3.2 for Hospital Pharmacy ervices 2, the RP Keeping patients safe when they transfer between care providers 5 getting the medicines right good practice guidance and Academy of Medical Royal Colleges tandards for the clinical structure and content of patient records 6 collectively set standards of how medicines related information should be communicated at care interfaces. The table below sets out the standards required when communicating medicines related information on the discharge summary when transferring from secondary care. 6.1 The discharge summary contains clearly documented details of patients First & last name Date of birth Address Hospital number NH number tandards Helpful Hints / Comments Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 55

56 Medicines Use and afety 6.2 The discharge summary contains clearly documented details of the General Practitioner: Address Contact telephone number 6.3 Reason(s) for admission are clearly documented on the discharge summary 6.4 Ensure that any allergies or nil history of allergies to medicines (NKDA) are clearly documented on the discharge summary and include the causative medication and brief description of reaction/outcome Medication Details 6.5 Ensure that all prescribed medication on the discharge summary is clearly written with its generic name (unless not appropriate for example bioavailability issues) 6.6 Ensure that all prescribed medication on the discharge summary has a clear indication documented for its use 6.7 Ensure that the dose of each prescribed medication on the discharge summary is clearly written in the correct units 6.8 Ensure that the frequency of each prescribed medication is clearly documented on the discharge summary 6.9 Ensure that the route of administration of each prescribed medication is clearly documented on the discharge summary 6.10 Ensure that the formulation of each prescribed medication is clearly documented on the discharge summary 6.11 Ensure that there is clear and unambiguous documentation on the duration and/or review of any medication on the discharge summary e.g antibiotic durations, dose titrations etc. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 56

57 Medicines Use and afety Medication Changes and Communication at Discharge 6.12 Ensure that there is clear and unambiguous documentation where any doses of medications have been changed from what the patient was prescribed prior to admission with a corresponding reason for the change on the discharge summary 6.13 Ensure that there is clear and unambiguous documentation where medicines have been discontinued during the admission with a corresponding reason for the discontinuation on the discharge summary 6.14 Ensure that there is clear and unambiguous documentation where a new medication has been commenced during the admission with a corresponding reason for the commencement on the discharge summary Ongoing Monitoring 6.15 Ensure that there is clear and unambiguous documentation of any therapeutic drug monitoring (TDM) that needs to be undertaken (and by whom) 6.16 Ensure that there is clear and unambiguous documentation of any on-going or follow up monitoring that is required related to drug therapy e.g LFTs,U&E s including clarification of responsibility NH Trusts should consider developing a list of medicines that require TDM monitoring 6.17 Ensure that there is clear and unambiguous documentation of any advice regarding medicines that are deemed specialist initiation only/hospital only/shared care/unlicensed etc. Contact Details 6.18 Where possible ensure that discharge summaries are clinically checked by a Pharmacist and their name and contact details are clearly and unambiguously documented on the discharge summary Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 57

58 Medicines Use and afety 6.19 The name and contact details of the discharging Dr is clearly and unambiguous documented on the discharge summary References: 1. National Institute for Health and Clinical Excellence (NICE). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. March 2015, available at: (Accessed 28th March 2015) 2. Royal Pharmaceutical ociety. Professional tandards for Hospital Pharmacy ervices - Optimising Patient Outcomes from Medicines. Version 2 July Available at (accessed 3rd Oct 2014). 3. World Health Organisation. The High 5s Project. tandard Operating Protocol - Assuring Medication Accuracy at Transitions in Care: Medication Reconciliation. Available at (accessed 4 th May 2015) 4. Institute for Healthcare Improvement. Medicines Reconciliation to prevent adverse drug events. Available at Pages/default.aspx (accessed 3rd Jan 2015). 5. Royal Pharmaceutical ociety. Keeping patients safe when they transfer between care providers getting the medicines right. July Available at (accessed 4th Nov 2014) 6. Academy of Medical Royal Colleges. tandards for the clinical structure and content of patient records. July Available at (accessed 4th Nov 2014) Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 58

59 Medicines Use and afety Chapter 4 Audit and Evaluation This chapter aims to provide guidance and tools that allow the audit of the Medicines Reconciliation process at both admission and at discharge. The chapter provides an overview of the principles underpinning audit, audit standards, data collection forms for undertaking the audits and some tips on how the audit results may be presented. Establishing and sustaining reliable Medicines Reconciliation processes is a challenge and it is imperative to monitor performance and drive improvement through audit and measurement. Both the audits described within this chapter are manual retrospective audits conducted through analysing patient medication charts, medical notes and/or other types of information sources. The principles of the audit are equally applicable to organisations that have paper based systems or electronic systems Principles of Audit Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery (NICE 2002). Fig 4.1 below describes the audit cycle, this chapter provides the tools to complete the audit cycle by identifying the topic to be audited, it sets the standards for the processes being audited, it provides the methodology and data collection tools along with tips on how the data may be analysed and presented. The implementing change aspect of the audit cycle is for the organisation undertaking to consider. Fig 4.1: The Audit Cycle Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 59

60 Medicines Use and afety Registration of Audit: It is recommended that the audit is logged and registered with the trust clinical governance/audit department and a reference number obtained particularly for the Medicines Reconciliation on Discharge/Discharge ummaries Audit as this will require the audit coordinator to obtain patient medical records. Audit tandards: The audit standards described within this chapter were developed through a consensus approach by the Medicines Reconciliation working group who kindly volunteered their time to contribute to the development of this toolkit. The working group discussed local procedures and practices, reviewed local, regional and national guidelines, policies and directives pertaining to Medicines Reconciliation. Example of references utilised in drawing up the audit standards include: National Prescribing Centre (NPC) Medicines Reconciliation - A Guide to Implementation, NH England Medication afety Thermometer, RP Keeping patients safe when they transfer between care providers guidelines, RP Professional tandards for Hospital Pharmacy ervices, NH England Patient afety Alert: Risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care and the Academy of Royal Medical Colleges tandards for the structure and content of medical records. Patient Confidentiality: For the purposes of the audits considered within this chapter there should not be any need to collect patient information that requires identification of the patient details such as name, surname, address or date of birth and therefore such data should not be collected. The audit coordinator may wish to record the patient s hospital number or NH number that allows data to match to the original patient information however you must consider how you will ensure the confidentiality of the data. ampling trategy: The audit standards developed are reflective of the best practice standards detailed in chapter 3. It is advised that both sets of audit standards are utilised where a comprehensive level 2 MR service is provided. It is important that your sample contains current or recent patients as audit is about improving current practices and processes. Consideration should be given on the timing of the audit particularly for the Medicines Reconciliation on Admission audit as both the day and the time may affect the results. A suggestion is to capture the potential best possible scenario by undertaking the audit between Tuesday and Thursday afternoon during non-school holidays. imilarly a worst case scenario could be audited such as Monday afternoon and results be compared to observe any differences. This comparison may support any management decisions and/or business cases for additional resources or 7 day working. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 60

61 Medicines Use and afety ample ize: The sample size for both audits will be largely governed by the time that is available and the number of staff involved in the data collection. The Medicines Reconciliation on Admission audit should allow a relatively large sample to be audited as the data collection should generally only include review of the drug chart which should not be time intensive and the audit could be organised such that several Pharmacists and/or Pharmacy Technicians could undertake the data collection simultaneously. The Medicines Reconciliation on Discharge / Discharge ummaries Audit may be restricted to a smaller sample size as the audit will involve reviewing the medical notes of patients retrospectively which may be a time consuming activity, in addition for more reliable results it would be preferable to have one individual undertaking the data collection. Although for research projects it is very important that a sample size is calculated in advance so its results are generalisable to a larger population, for the purposes of a process based clinical audit there is no such need, however, the sample should be large enough so that senior clinicians and managers are willing to implement changes based on the findings. As a general rule of thumb 1, a sample size of greater than 30 allows the accuracy of the final estimate to be reasonable, a sample size of 50 allows greater confidence in the results however beyond a sample size of 100 there is little to be gained in terms of confidence in accuracy of results with each extra piece of information that is collected. Data Collection: The data collection forms for both audits that have been developed can be found in appendix 1. The design of the data collection form assumes that the results will be transferred onto a Microsoft excel spreadsheet for data analysis. Data Analysis: Audit data generally comes in three different forms, tick-box, numerical or free text. The audits described in this chapter utilise tick box and numerical data forms. In each case the aim is to establish which standards are being met (% compliance) and which are not (% non-compliance). If a standard is not being met it is important to identify why and how the practice and/or process can be improved to ensure that the standard is met in the future. Within the discussion it would be important to consider if there were other, acceptable reasons for the standard not being met. The data being collected within this audit generally relates to yes/no options, tick-box options from a specified list of alternatives or numerical data that is captured as a fraction. It is usual practice to add up the number of answers recorded for each option and express the total as a raw number and as a percentage. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 61

62 Medicines Use and afety EXAMPLE 1: ample size (n): 50 patients Audit tandard: The patient s medication regime prior to admission is clearly documented on the appropriate section of the drug chart/medical notes/ electronic prescribing system or other system. Audit question: Has the patient s medication regime prior to admission been clearly documented on the appropriate section of the drug chart/medical notes/ electronic prescribing system or other appropriate location? Results: Yes = 32 and No = 18. A good way of expressing this data is: The patient s medication regime prior to admission is clearly documented on the appropriate section of the drug chart/medical notes/ electronic prescribing system or other o Yes = (32/50, 64%) EXAMPLE 2: ample size (n): 50 patients that have a total of 250 drugs prescribed between them Audit tandard: The frequency of each prescribed medication must be clearly documented on the discharge summary Audit question: Is the frequency of each prescribed medication clearly documented on the discharge summary? Results: 235 medicines did have the frequency of dosing specified clearly whereas 15 medicines did not A good way of expressing this data is: (235/250, 94%) of medicines did have their frequency of dosing clearly The n=250 indicates the total number of medicines in the audit sample and is used to calculate the percentages, i.e. 235/250 = 94%. The majority if not all of the data generated within the two audits described in this chapter can be classified as categorical data which is data that can be sorted according to non-overlapping (mutually exclusive) categories, whereby each subject in a sample can only fit into one category. This type of data is most commonly presented as a bar chart or a pie chart. Consideration should be given to whether the data should be collected in a manner that allows comparison between different hospitals (within a trust), directorates, care areas, levels of Pharmacy support and/or resource provided to the care area being audited etc. so that patterns in practice between different areas/groups can be analysed. Other measures within the Medicines Reconciliation on Discharge/Discharge ummaries Audit that may allow stratification of data and thus comparison are Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 62

63 Medicines Use and afety whether the discharge summary was screened by a Pharmacist or not, whether the discharge prescription was electronically generated or hand written and whether a MR was conducted on admission or not for the discharge summary generated. ignposting to Audit upport: Within NH organisations there may be a specific audit team that can provide support and advice, this team is usually located within the clinical governance team. The table below signposts readers to resources that may support the audit process: Table 4.1: ources of Audit upport Audit Resources The Health Quality Improvement Partnership (HQIP) Intermediate level clinical audit training for clinicians (Apr 2012) The Health Quality Improvement Partnership (HQIP) Criteria and indicators of best practice in clinical audit The Royal Pharmaceutical ociety provides its members with Audit support and guidance. They also have a useful toolkit available. Description of resource This elearning package is comprised of four complimentary sessions. Covering 1-2 hours total study time, these four elements are: 1 - Thinking about doing clinical audit; 2 - Identifying and collecting data; 3 - Analysing and interpreting data; 4 - Feedback and changing practice. The purpose of this guidance is to define the markers or indicators of good quality clinical audit, at both national and local level, conducted by both individuals and more commonly, by teams. The Royal Pharmaceutical ociety can support you in preparing for and conducting your clinical audits so that you can demonstrate your excellent services and identify areas where you can enable real improvements. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 63

64 Medicines Use and afety 4.2 Auditing the Medicines Reconciliation Process This section provides the tools for organisations to audit their Medicines Reconciliation processes. The section focusses on the two key areas of MR: Medicines Reconciliation on Admission and Medicines Reconciliation on Discharge. Audit standards that can be easily measured in practice have been developed based on the standards described in chapter 3. Instructions on how to conduct the audit is detailed and data collection tools are available in the appendices. Audit Methodology for MR on Admission: Guidance Notes The audit should be carried out on wards that are designated to receive a Pharmacy service that includes level 2 MR service as routine (If all wards within the hospital are audited, results should be broken down by ward in order to contextualise results against Pharmacy resource and patient turnover) Trusts may choose to audit ALL of the wards/units or just a sample of wards All patients admitted to the ward/care setting should be audited The ward/units chosen for audit may admit planned, unplanned or a mixture of patients If patients are primarily admitted through an admissions unit where Level 2 MR is offered it is suggested that this unit and other ward areas where patients are transferred are audited The audit should be carried out on all nominated wards at the same time, this will facilitate an overall picture of the extent of level 2 MR delivery at any given point in time within the trust. Data should be collected on one day only, as a snap shot audit which could be repeated at intervals that are far enough apart (e.g. beyond the average length of stay for the care area being audited) so that it has little risk of capturing duplicated data Consider the day of audit to be Tuesday, Wednesday or Thursday so that it reflects optimal performance. If resources allow it would be worthwhile to audit Monday as a comparator to observe if there are any differences in results due to possible lower staffing levels over the weekend. It is anticipated that the audit will require the examination of the drug chart (or electronic prescribing system) and possibly clinical notes if relevant Instructions for Carrying out the Audit 1. Review Medicines Reconciliation on admission audit standards in Table Review Medicines Reconciliation on admission audit data collection tool (Appendix 1) 3. Print off enough Medicines Reconciliation on admission audit data collection tool forms (appendix 1) for one form per patient being audited Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 64

65 Medicines Use and afety 4. Review drug chart/electronic prescribing systems and/or medical notes if appropriate for each patient being audited in order to complete the data collection tool 5. Transfer data from each data collection tool onto a formatted excel spreadsheet 6. Manipulate the excel spreadsheet to generate audit results Table 5.1.1: Audit tandards for Medicines Reconciliation on Admission Audit tandard Target Measure Guidance Notes 1 All patients must have a MR undertaken by a member of the Pharmacy team the day of, or 100% No of patients for which All of the the day following, admission. a level 2 MR has been discrepancies conducted within identified DO NOT specified time need to have been parameters / Total fully resolved by the number of patients Pharmacy team to audited satisfy the standard To continue audit for those patients that have received a level 2 Medicines Reconciliation (note denominator will change) 2 It is clearly identifiable and documented (name and signature) in the appropriate patient 100% Yes/No records who has completed the level 2 MR 3 It is clearly identifiable and documented (date of completion) in the appropriate patient 100% Yes/No records when the level 2 MR was completed 4 The patient s medication regime prior to admission is clearly documented on the appropriate section of the drug chart/medical notes/ electronic prescribing system or other process 100% Yes/No Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 65

66 Medicines Use and afety 5 Any newly prescribed medicine at the time of MR is clearly documented on the drug chart/medical notes/ electronic prescribing system or other to indicate that this medication has been commenced on admission 6 A reason for any newly prescribed medicines must be clearly documented on the drug chart/medical notes/ electronic prescribing system or other process. 7 Any medicines intentionally stopped at the time of MR must be clearly documented on the drug chart/medical notes/ electronic prescribing system or other to indicate that this medication has been stopped on admission 8 A reason for any medicines intentionally stopped must be clearly documented on the drug chart/medical notes/ electronic prescribing system or other process. 9 Any intentional changes to medicines (i.e Dose, Route, Formulation) at the time of MR must be clearly documented on the drug chart/medical notes/ electronic prescribing system or other to indicate that change. 10 Any unintentional discrepancies identified during the level 2 MR must be clearly documented on the drug chart/medical notes/ electronic prescribing system or other process. 100% Yes/No A medication 100% No of new medicines discrepancy may be either intentional or unintentional. Both commenced with a clearly documented reason / Total number of newly commenced medicines 100% Yes/No 100% No of medicines intentionally stopped with a clearly documented reason / Total number of medicines intentionally stopped 100% Yes/No 100% Yes/No types of discrepancies should be documented either in the clinical notes/drug chart or electronic prescribing system. An example of an intentional discrepancy would be when a medication has been withheld due to it causing an adverse side effect or prior to surgery. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 66

67 Medicines Use and afety 11 Any allergies or nil history of allergies to medicines (NKDA) must be clearly documented on the drug chart/medical notes/ electronic prescribing system or other and include the causative medication and brief description of reaction/outcome 100% Yes/No An unintentional discrepancy is defined as an error or omission in the medication history. The medication may have been omitted from the list, or the wrong drug, dose, frequency or route may have been documented or prescribed. 12 A minimum of 2 sources of evidence must be used to confirm the MR and are documented in the appropriate section of the drug chart/medical notes/ electronic prescribing system or other process. 100% Yes/No Data Collection form breaks down sources used to identify prevalence of sources used Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 67

68 Medicines Use and afety Audit Methodology for MR on Discharge/Discharge ummaries Audit: Guidance Notes This is a retrospective case note quality audit in which NH trusts review a random sample of their own discharge summaries that they have sent to the next caregiver (General Practitioners in the majority of cases) This type of audit is best suited to be conducted as a project by an individual who has protected time to carry out the audit. The individual in question must have a good level of clinical knowledge, pharmaceutical skills and ability to navigate the medical notes. Pre-Registration Pharmacists under the supervision of a Pharmacist would be appropriate candidates to conduct this audit. When identifying patients/discharge summaries to audit, it would be prudent to exclude: o Patients Admitted for less than 24 hours o Planned admissions e.g urgery, Maternity etc. (the rationale behind the exclusion is that discharge summaries for planned admissions often do not document the patient s regular medication, combing this data with unplanned admissions may dilute any findings) o Deceased whilst in hospital It may be advisable to audit particular wards (e.g High turnover of medical patients, known risks etc) It is important to log this audit with the trust audit team and obtain a reference number. This will aid the audit coordinator in obtaining in any information from medical records. Instructions for Carrying out the Audit 1. Review Medicines Reconciliation on discharge/discharge summaries audit standards in Table Review Medicines Reconciliation on discharge/discharge summaries audit data collection tool (Appendix 2) 3. Print off enough Medicines Reconciliation on discharge/discharge summaries audit data collection tool forms (appendix 2) for each discharge summary being audited 4. Obtain a list (including patient details) of patients discharged from the NH Trust over the last 3 months from the trust information, audit department or electronic discharge system. When requesting the information ask the trust information or audit department to remember to exclude patient groups noted above in the guidance notes Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 68

69 Medicines Use and afety 5. Number each patient on the list starting from 1. Use consecutive sampling methodology to identify patients to be audited for example choosing every 5 th patient or every 3 rd patient to be audited. Consecutive sampling methodology is an example of non-probability sampling and although it is important to remember that the sample produced may differ in character from the overall population and therefore the audit results may not be representative of the overall care that is given it is the most practical way of selecting cases for a snapshot sample of the population. 6. The total number of patient discharge summaries to be audited (sample size) can be calculated by the NH Trust dependant on time and resources. As a guide the sample size selected for a process-based clinical audit project should be large enough so that senior clinicians and managers are willing to implement changes based on the findings. In terms of clinical audit a snapshot sample of roughly cases, for a process-based audit this is usually sufficient. This will enable you to measure whether processes are being followed as per the standards set. 7. Obtain the final discharge summary sent to the next caregiver for all the patients identified. If using an electronic discharge system this should be relatively simple, if using a paper based discharge system this will involve locating a copy of the paper discharge summary which should be available within the Pharmacy. 8. Obtain the medical notes/drug chart/electronic system prescribing information regarding each of the patients being audited 9. Complete the data collection tool using the discharge summary, medical notes, drug chart and electronic prescribing information if applicable 10. Transfer data from each data collection tool onto the formatted excel spreadsheet available within the toolkit 11. Manipulate the excel spreadsheet to generate audit results Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 69

70 Medicines Use and afety Table 5.1.2: Audit tandards for Medicines Reconciliation on Discharge/Discharge ummaries Audit tandard Target Measure Guidance Demographics 1 The patient s complete details including last name, first name, date of birth, patient address, hospital number and NH number must be clearly identifiable and documented on the discharge summary 2 The patients General Practitioner details including named GP, address and contact telephone number must be clearly identifiable and documented on the discharge summary 3 The reason(s) for admission must be clearly identifiable and documented on the discharge summary 100% Yes/No Data collection form can breakdown individual identifiers to identify any particular issues 100% Yes/No Data collection form can breakdown individual identifiers to identify any particular issues 100% Yes/No Note: All patient identifiers MUT be present for the standard to be met Note: All GP identifiers MUT be present for the standard to be met Allergy Compliance 4 Any allergies or nil history of allergies to medicines (NKDA) must be clearly documented on the discharge summary and include the causative medication and brief description of reaction/outcome Medication Details 100% Yes/No Note: For the standard to be met BOTH the name of the medication causing the allergy and the description of the allergy reaction must be present) Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 70

71 Medicines Use and afety 5 All prescribed medication on the discharge summary must be clearly written with its generic name (unless not appropriate for example bioavailability issues where brand name is acceptable) 6 All prescribed medication on the discharge summary must have a clear indication documented for its use e.g. Oxybutynin 5mg M/R Tablets PO OD for Urinary Incontinence 7 The dose of each prescribed medication on the discharge summary must be clearly written in the correct units e.g Oxybutynin 5mg M/R Tablets PO OD for Urinary Incontinence 8 The frequency of each prescribed medication must be clearly documented on the discharge summary e.g Oxybutynin 5mg M/R Tablets PO OD for Urinary Incontinence 9 The route of administration of each prescribed must be clearly documented on the discharge summary e.g Oxybutynin 5mg M/R Tablets PO OD for Urinary Incontinence 100% Number of medicines prescribed appropriately as generic / Total number of medicines prescribed 100% Number of medicines prescribed with indication / Total number of medicines prescribed 100% Number of medicines prescribed with clear and correct dose instructions / Total number of medicines prescribed 100% Number of medicines prescribed with clear and correct dosing frequency instructions / Total number of medicines prescribed 100% Number of medicines prescribed with clear and correct route of administration instructions / Total number of medicines prescribed The denominator for all of these standards is should remain the same i.e the total number of medicines prescribed on the discharge summary Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 71

72 Medicines Use and afety 10 The formulation of each prescribed medication must be clearly documented on the discharge summary e.g Oxybutynin 5mg M/R Tablets PO OD for Urinary Incontinence 11 There must be clear and unambiguous documentation on the duration and/or review of each medication (if applicable) on the discharge summary e.g antibiotic durations, dose titrations etc. 100% Number of medicines prescribed with clear and correct formulation instructions / Total number of medicines prescribed 100% Total no of medicines prescribed with clear and correct duration and/or review instructions / Total no of medicines prescribed where duration or review is relevant Medication Changes and Communication at Discharge 12 There must be clear and unambiguous documentation where any doses of medications have been changed from what the patient was prescribed prior to admission with a corresponding reason for the change on the discharge summary 100% Number of medicines that document dose changes clearly and unambiguously / Total number of medicines that have had dose changes or possible changes 13 There must be clear and unambiguous documentation where medicines have been discontinued during the admission with a corresponding reason for the discontinuation on the discharge summary 100% Number of medicines that document discontinuation clearly and unambiguously / Total number of medicines that have Note denominator is different to the above denominator This section of the audit will require retrospective case note review and involves effectively rescreening the discharge summary from the information contained within the medical notes including the drug chart Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 72

73 Medicines Use and afety 14 There must be clear and unambiguous documentation where a new medication has been commenced during the admission with a corresponding reason for the commencement on the discharge summary Ongoing Monitoring 15 There must be clear and unambiguous documentation of any therapeutic drug monitoring (TDM) that needs to be followed up including clarification of responsibility (NH Trusts to determine a list of Drugs that require TDM monitoring). 16 There must be clear and unambiguous documentation of any on-going or follow up monitoring that is required related to drug therapy e.g LFTs,U&E s including clarification of responsibility (Note: Use Clinical Judgement) 17 There must be clear and unambiguous documentation of any advice regarding medicines that are deemed specialist initiation only/hospital only/shared care/unlicensed been discontinued or possibly discontinued 100% Number of medicines that document new initiation clearly and unambiguously with reason(s) / Total number of medicines that have been initiated 100% Number of medicines that have clear documentation on follow up TDM / Total number of medicines that require TDM (as per NH Trust list) 100% Number of medicines that have clear documentation on follow up monitoring / Total number of medicines that require follow up monitoring 100% Number of medicines that have clear advice regarding specialist initiation only, hospital only, shared care, unlicensed medicines / Total number of This section of the audit will require the investigator to use their clinical judgement Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 73

74 Medicines Use and afety medicines that are designated specialist initiation only, hospital only, shared care, unlicensed medicines Contact Details and tratification 18 Was the discharge summary clinically screened by the Pharmacist? N/A Yes / No Allows stratification of results into Pharmacy screened TTAs and Non Pharmacy screened TTAs 19 If Yes, there must be clear and unambiguous documentation of the name and contact details of the screening Pharmacist on the discharge summary 100% Yes / No 20 There must be clear and unambiguous documentation of the name and contact details of the discharging Dr on the discharge summary 100% Yes / No 21 Was the Discharge ummary Electronic or Hand written N/A Electronic / Hand written Allows stratification of results into electronic or handwritten Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 74

75 Medicines Use and afety Case tudy for MR on Discharge /Discharge ummaries Audit The Medicines Reconciliation on Discharge/Discharge ummaries Audit tandards was piloted at Ealing Hospital in West London and Oxford University Hospitals simultaneously to validate the audit methodology. Both sites were able to conduct the audit with relative ease, Oxford University Hospitals have an electronic prescribing system which made data retrieval somewhat easier and reduced the need to refer back to the medical notes. The audit investigator at Ealing Hospital kept contemporaneous notes on how they conducted the audit in a step by step manner, this contemporaneous account may support other audit investigators when conducting the audit and can be viewed via amperaneous%20audit%20methodology_may%2015.pdf. At Ealing Hospital the audit results were used as a tool to generate discussion within a focus group that was set up to improve the quality of Pharmacist TTA screening. Both audit investigators are happy to be contacted for further information on how they conducted the pilot audit. Reena Devit at Ealing Hospital on reenadevit@nhs.net Cate Leon at Oxford University Hospitals on cate.leon@ouh.nhs.uk References and Acknowledgements: 1. Wright D. NH East of England Audit Package. Version University Hospital Bristol NH Foundation Trust. Clinical Audit - How to Guide? Available at (Accessed 27 th Feb 2015) Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 75

76 Medicines Use and afety Chapter 5 Education, Training and Competency The NICE Medicines Optimisation Guidance: the safe and effective use of medicines to enable the best possible outcomes published in March 2015 states that organisations should ensure that Medicines Reconciliation is carried out by a trained and competent health professional ideally a Pharmacist, Pharmacy technician, Nurse or Doctor with the necessary knowledge, skills and expertise including: effective communication skills, technical knowledge of processes for managing medicines and therapeutic knowledge of medicines use. In support of the above guidance this chapter aims to set out the necessary competencies required to undertake Medicines Reconciliation whilst also signposting to a variety of educational and training resources that support the development of staff to obtain the necessary knowledge, skills and competencies to undertake MR. 5.1 Key Competencies for taff Conducting Medicines Reconciliation This section shares the key competencies that staff must develop and possess when conducting Medicines Reconciliation. The competencies are applicable to all Pharmacy staff (Pharmacists, Pharmacy Technicians and Pre-Registration Pharmacists) and should also be used with Nursing, Medical or any other staff involved in carrying out Medicines Reconciliation. The competencies and their behaviours are drawn from three national documents; The Royal Pharmaceutical ociety Foundation Pharmacy Framework, The Foundation Pharmacy Framework for Pharmacy Technicians developed by the Association of Pharmacy Technicians UK and the Nationally Recognised Competency Framework for Pharmacy Technicians: Competency Behaviours developed by NH Pharmacy Education & Development Committee. The frameworks should be viewed individually and in their entirety to ensure that practitioners are competent in the all of the underpinning skills and competencies that are essential for them to deliver any medicines management activity including Medicines Reconciliation. Table below displays these competency frameworks in more detail with links to the full documents. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 76

77 Medicines Use and afety Table 5.1.1: National Competency Frameworks The Royal Pharmaceutical ociety Foundation Pharmacy Framework Association of Pharmacy Technicians UK Foundation Pharmacy Framework Nationally Recognised Competency Framework for Pharmacy Technicians developed by NH Pharmacy Education & Development Committee The Foundation Pharmacy Framework (FPF) will support you to achieve the core skills, knowledge and behaviours that are essential for all Pharmacy practitioners. A blend of these key components provides a baseline for safe and effective Pharmacy practice which underpins all roles within Pharmacy practice and ensures a foundation of essential skills which can be built on depending on your focus and expectations for career development The purpose of this document is to provide guidance on a competency framework that supports the development of Pharmacy technicians as safe, effective practitioners. The overarching aims of the framework are to standardise the quality, productivity and efficiency of medicines management training and assessment programmes for Pharmacy technicians across the UK, and to provide a method of quality assurance. In table below an attempt has been made to describe the key competencies (drawn from the competency frameworks described above) required by practitioners to undertake Medicines Reconciliation activities. The RP Foundation Pharmacy Framework Competency Framework and Association of Pharmacy Technicians UK Foundation Pharmacy Framework behavioural statements provide the overarching principles of good practice required during MR whilst the Nationally Recognised Competency Framework for Pharmacy Technicians: Competency Behaviours developed by NH Pharmacy Education & Development Committee provides more prescriptive guidance. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 77

78 Medicines Use and afety Table 5.1.2: Key Competencies Required for taff Conducting Medicines Reconciliation The RP Pharmacy Foundation Framework Competency Behaviours and Association of Nationally Recognised Competency Pharmacy Technicians UK Foundation Pharmacy Framework Framework for Pharmacy Technicians: Competency Behaviours Consultation and Communication kills 1.1 atisfactorily obtains patient consent if appropriate Obtain valid consent from the patient (or carer) in accordance with the organisation s procedures Take appropriate actions if consent is not obtained, not available or declined, in accordance with organisation s procedures 1.1 Uses appropriate questioning to obtain all relevant information from the patient Record the individual s social habits where applicable 1.1 Documents consultations where appropriate in the patient s records Where applicable, in accordance with legislation and the organisation s procedures relevant to writing in patients medical notes 2.3 Communicates clearly, precisely and appropriately with: Introduce self to the patient and explain the - Patient and carer intention of the consultation - Health care professionals - Others Information Gathering and Documentation 1.2 Retrieves relevant or available information Identify the information needed when obtaining a medication history Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 78

79 Medicines Use and afety Where only one source of information is available, document that a follow up is required with a second source for confirmation 1.2 Documents an accurate and comprehensive medicines history when required Record information sources used Record details of ALL medications being taken on the appropriate documentation Record details of ALL non-prescription medicines Identify when ALL the medications have been reconciled and sign and date the appropriate documentation ensuring that it is filed in the correct location 1.3 Ensures the prescriber s intentions are clear for any patient Document the status of all the medications on the appropriate documentation, which could include: topped and changed medicines Newly prescribed medicines Document any new prescriptions or medications stopped or altered 3.1 Is able to access information from appropriate information sources Use a range of sources of information 3.1 Keeps concurrent information needed on a day to day basis Information Analysis and Decision Making Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 79

80 Medicines Use and afety 3.3 Is able to analyse and synthesise key elements from information gathered Identify and document any medication related problems that the patient may have Compare the verified medication history obtained with the most recent valid prescription or documentation available Identify and document discrepancies between the accurate medication history and the medicines prescribed on the current medication record Record details of any discrepancies ign and date the relevant documentation and ensure that it is filed in the appropriate location 3.3 Demonstrates a logical process to problem solving Take appropriate action if discrepancies are found between the sources Recognise the limitations of a single source and the reasons for always checking with a further source Confirm whether the identified changes or omissions have been made intentionally Liaise with the appropriate people to resolve clinical queries and unexplained/unintentional changes 3.3 Demonstrates clear decision making Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 80

81 Medicines Use and afety 3.5 Ensures resolution of problem Document the outcome of the resolution of any queries In order to ensure that the skills, knowledge and competencies possessed to undertake MR activities are kept up to date organisations and practitioners may wish to utilise work based assessment tools such as the Mini Clinical Evaluation Exercise (Mini CEX) and Medicines Related Consultation Framework (MRCF) which enable practitioners with the support of a senior colleague or peer to evaluate their own performance with a real patient and have real time feedback. These tools are utilised within the RP Foundation chool Pharmacy Postgraduate Courses and are relatively easy to use. For the tools themselves and information on how to use them please see the JPB website It is acknowledged that Pharmacy technicians that have completed nationally approved medicines management training and assessment programme are required to undergo a reaccreditation process every 2 years. 5.2 Collation of Education and Training Materials upporting the Medicines Reconciliation Process The need for a wide range of people to be trained to deliver Medicines Reconciliation has increased as a result of the increasing national focus on the risks during transfer of care of patients in all care sectors and the increase in the development of care pathways that deliver care closer to home which may not always have a dedicated clinical Pharmacy service. Table 5.2 signposts the reader to a variety of training programmes, training frameworks and educational materials that support the delivery of Medicines Reconciliation. It also provides an opportunity for organisations/departments/individuals to review their current training provision and compare it to other examples to ensure that what is provided locally is suitable. Table 5.2 has been divided such that resources are categorised into: A) Nationally available training and B) Regionally developed training. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 81

82 Medicines Use and afety Table 5.2: Collation of National and Regional Education and Training Materials upporting the Medicines Reconciliation Process ection A: National MR training programmes and resources Training Provider Description of Resource Centre for Pharmacy Postgraduate Education (CPPE) es/l/medsrecon-h-01/ Training Resource: Learning at Lunch Module: Medicines Reconciliation (Reviewed 2014) This learning resource is a Level 1 Learning at Lunch Module aimed at pre-registration and registered Pharmacists and Pharmacy technicians. Overview: The purpose of this programme is to support Pharmacists and Pharmacy technicians in taking a structured approach to reconciling medicines for patients in the acute setting. It focuses on the reconciliation of medicines within 24 hours for patients who are admitted to acute (and mental health) trusts, as required by NICE guidance. It may be used to complement local training on Medicines Reconciliation within acute trusts. The programme involves about four hours of study and has a format where participants complete an initial pre-session workbook (Booklet 1) followed by an on-site workshop. The lunchtime facilitated session involves looking at the case studies in more detail with questions for participants to work through (Booklet 2). There are suggested answers and also some suggestions for further practice-based activities. Complementary resources for running the case studies - a number of sources for drug histories, for example - are being made available for facilitators to download from the website. There is no e-assessment for the programme. Cost: Free for registered and pre-registration Pharmacists and Pharmacy technicians Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 82

83 Medicines Use and afety East and outh East England pecialist Pharmacy ervices (MU Division) ies/nelm/p-e-and-e- England/Meds-use-and-safety/ Training Resource: A Training Package to support the delivery of Level 2 Medicines Reconciliation by Pharmacy taff (2009) Overview: This package is intended to support education and training leads to develop on-site training as well as individual practitioners in acquiring the knowledge and skills to deliver MR effectively. It is linked to the template MR policy and outcomes from a MR survey both of which are available on the same web-site. The contents provide a series of learning outcomes needed to deliver MR. The sections that follow provide information, questions and case scenarios and signposts users to relevant resources to meet these learning outcomes. Advice is given about how to add in assessments for knowledge and competency. The learning outcomes are mapped to the General Level Competency Framework (GLF) and the Framework for Pharmacy Technicians (weblink to CoDEG) which are the previous versions of the RP Foundation Pharmacy Framework and the Foundation Pharmacy Framework for Pharmacy Technicians. The package was developed in collaboration with the regional NH Pharmacy education and training organisations within the P service area. Cost: Free NH Pharmacy and Education Development Committee Training Resource: Nationally Recognised Competency Framework for Pharmacy Technicians: The Assessment of Medicines Management kills Overview: The development of this framework was commissioned by the NH Pharmacy Education and Development Committee (PEDC) in response to the Department of Health White Paper Equity & Excellence, Liberating the NH and the Quality, Innovation, Productivity and Prevention (QIPP) agenda. The framework has been developed by a Working Group that includes medicines management Pharmacy technician specialists and education and development specialists representing all regions within the United Kingdom. This framework is intended to be used by training providers who: Plan to develop medicines management training and assessment programmes for Pharmacy technicians Currently deliver medicines management programmes and wish to assess the quality of their programmes against a nationally recognised standard Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 83

84 Medicines Use and afety This framework focuses on three aspects of the Pharmacy technician medicines management role and has been developed into three modules, each following the same format: The supply of medicines to individual patients The assessment of Patients Own Drugs Medicines Reconciliation The framework also describes the underpinning skills that are connected to and interwoven throughout each of the three modules enabling the medicines management role to be carried out to its full potential and to promote quality of care and patient safety. The Medicines Reconciliation module describes learning outcomes, against which competency can be assessed for Pharmacy technicians undertaking Medicines Reconciliation within the relevant care setting. It also encompasses the identification of discrepancies and issues that may arise as part of the process and dealing with these in an appropriate manner. A knowledge and competency-based approach to assessment is recommended and advice is provided about what should be assessed. ection B: Regional Training Programmes Training Provider Description of Resource outh West Medicines Information / Commercial and Academic ervices (CoAc) Training Resource: Medicines Reconciliation Training Programme Overview: The outh West Medicines Information and Training / CoAc system delivers an online programme covering the process of Medicines Reconciliation and prepares learners with the skills and knowledge necessary to enter into a more detailed training programme. The learning material comprises four modules which learners have to complete sequentially, taking them Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 84

85 Medicines Use and afety WMiT Website: Man.htm E Learning Webpage: n.com/ NH PE+D (NH Pharmacy Education and Development) Contact: Melanie Boughen: M.Boughen@uea.ac.uk. To discuss how a Trust uses this programme contact June mart at the West uffolk Hospital at June.mart@wsh.nhs.uk through the introductory basics, medication history taking, verifying this history (level 1) and reconciling medications prescribed on admission (level 2). An assessment system tests learners knowledge of both levels in order. Once level one is complete and a certificate issued, level two assessment becomes accessible. As proof that the learner has demonstrated a suitable level of competence, a certificate can be printed after passing each assessment. In addition, a reflective diary log is available for each learner to record their learning experiences. The activity of each learner is monitored by an assessor who is assigned a number of learners at the same institution. Assessors can grant or deny access to each learner in their group and authorise the awarding of certificates after evaluating the learners answers in the level 1 and 2 assessments. They can also give feedback to comments made in learners reflective diary logs. Assessors are chosen by Organisational leads, of which there is usually only one in each organisation. Leads have substantial administrative control and have the ability to grant site access to both learners and assessors and assign the latter their respective groups of learners. Leads can designate authority to capable assessors and need only concern themselves with the system operation rather than individual assessment. Cost: One-year subscription for the package: ite Licence VAT allows 50 users (excluding assessors and organisational leads) Training Resource: Medicines Reconciliation Training cheme for Pharmacy taff Overview: This training scheme has been adapted from a training package originally developed by a partnership between the Clinical Directorate and E & T pecialists from the East and outh East England pecialist Pharmacy ervices. The scheme uses a local trainer (who attends a regional session to support them in delivering the training) and overall programme facilitator (who attends a regional session for this role). The scheme is aimed at Pharmacists, Pre-registration Trainee Pharmacists and Pharmacy Technicians who are new to the role and have never received formal training in Drug History Taking, Medicines Management or Clinical ervice and where Medicines Reconciliation is a requirement of their job role Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 85

86 Medicines Use and afety Web-site: Direct Link to Training: macy-technicians/accreditedmedicines-reconciliation/ The Training cheme consists of two modules with separate learning outcomes that are mapped to the KF, General Level Framework, GPhC Registration trainee framework and the Framework for Pharmacy Technicians : Module 1 Drug History Taking Medicines Reconciliation Both modules are supported by in-house or regional study days to provide the underpinning knowledge required. Assessment is both knowledge and competency based. The knowledge is assessed via completion of a questionnaire. Outcomes from this identify knowledge gaps that can be filled by attending in-house or regional study sessions. The competency assessment framework is similar for the two modules. It involves observed completion of 10 Drug Histories and 10 MRs with OCEs available should essential criteria not be covered by the in-practice observed activity. A portfolio is also completed to document the observed practices that have been undertaken, ensure that a breadth of experience has been covered and highlight areas where further training is required using reflective practice. Health Education Kent urrey ussex; Pharmacy Education Website: Contact: lauramcewensmith@kss.hee.nhs.uk. To discuss how a Trust uses this programme contact Julie Bole Training Resource: National Medicines Management Accreditation Overview: This programme has been developed to support and enhance the delivery of medicines management across the NH and in particular the roles of Pharmacy technicians contributing to this agenda. This is a nationally recognised accreditation and as such will be transferable throughout the United Kingdom. HE K recognise that delivery in individual work bases is diverse; this programme does not attempt to prescribe one single model for the delivery of medicines management. Neither does it aim to be a clinical knowledge course. This programme is recommended for Pharmacy Technicians registered with the General Pharmaceutical Council. However, HE K Pharmacy will accept applications from any NVQ2 (or above) qualified Healthcare Professional, depending on the relevance Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 86

87 Medicines Use and afety (Western ussex Hospitals NH Trust) to their job role and if supported or nominated by their Trust. Trusts within HE K use the course framework as a basis for their pre-registration Pharmacist MR training. The training programme combines practice activities, portfolio requirements, practice-based assessments and a summative OCE assessment to provide knowledge and competency-based accreditation scheme. The programme also enables trainers to be accredited to deliver the programme locally. The training is delivered through three modules and the scheme offers Trusts and candidates a choice in the modules of the Accreditation that they want to complete depending on how relevant the module is to their job role: Module 1 Patient s Own Drugs (PODs) and Medicines upply Module 2 Medicines Reconciliation Module 3 Device Counselling Cost: K Pharmacy training is funded for all staff in Kent, urrey, East and West ussex, Hampshire and the Isle of Wight from NH Hospitals, NH Community Trusts Mental Health Trusts and prisons. For all private organisations or NH staff outside the K and H&IOW region, the cost of this Accreditation is 400. Please visit HEK Terms and Conditions page for further information. 5.3 Local Examples of MR Education and Training The table below details local examples of training approaches that have been shared by NH organisations on how they deliver their education, training and competency assurance with respect to MR. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 87

88 Medicines Use and afety Table 5.3: Collation of Local Education and Training Materials upporting the Medicines Reconciliation Process Organisation: Northwick Park Hospital Key Contact: Fiona Turnbull on or Mira Jivraj on Junior Doctors Training: At Northwick Park Hospital clinical Pharmacists carry out training for junior doctors (FY1s) on Medicines Reconciliation annually as part of the FY1 training program. The one hour mandatory teaching session for FY1 junior doctors is delivered within their first two months at the Trust. This is delivered using PowerPoint slides and handouts and is combined with brief training on writing TTAs. The presentation covers the types of sources that can be used for Medicines Reconciliation with advantages and disadvantages. The slides include real examples of sources and ask the doctors to identify the limitations and include examples of errors that have happened at the Trust. The presentation also includes information on how to document changes made to medication in hospital. A Medicines Reconciliation scenario is included in the FY1 prescribing assessment. The assessment is passed if the answer is deemed clinically safe. Feedback is given verbally during a training session and on an individual feedback form. Pre-Registration Pharmacists Training: Clinical Pharmacists carry out training for pre-registration Pharmacists. This includes reading the Medicines Reconciliation policy and observing a clinical Pharmacist carrying out at least five medicine reconciliations. The pre-registration Pharmacist is then observed and assessed carrying out a minimum of three Medicines Reconciliations before being signed as competent to complete Medicines Reconciliation without direct observation. Following on from this they will be asked to complete a further 10 Medicines Reconciliations to gain exposure to different types of patients. If any of the Medicines Reconciliations are not satisfactory the pre-registration Pharmacist will have to repeat the assessments until the supervising Pharmacist is confident to sign them off. Preregistration Pharmacists have a specific clinical training program that includes Medicines Reconciliation. Newly Employed Pharmacists: Newly employed Pharmacists are requested to read the Medicines Reconciliation policy, complete the clinical induction pack which includes a section on Medicines Reconciliation and carry out a ward based Medicines Reconciliation accreditation assessment as part of their departmental induction. The newly Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 88

89 Medicines Use and afety employed Pharmacist is requested to undertake a ward based assessment of their clinical Pharmacy skills by one of the senior Pharmacists. Assessment takes place in the form of the clinical induction pack which includes a series of questions based on the Medicines Reconciliation process. In addition the newly employed Pharmacist must observe a Pharmacist undertaking 3 Medicines Reconciliation and then themselves must be observed undertaking 3 Medicines Reconciliations to be signed off as competent. ubstantive Pharmacy taff: A comprehensive training session is delivered to the entire Pharmacy department every 1-2 years. There is currently no assessment or reaccreditation that takes place. Medicines Management Technicians Medicines Management Technicians (MMT) need to complete an accreditation programme if they undertake Medicines Reconciliations as part of their role. MMTs who have not previously carried out Medicines Reconciliations are required to complete either an in-house training programme or the London Pharmacy Education and Training (LPET) AIMM course. Newly employed MMTs with prior experience can complete a fast-track accreditation programme. Ongoing assessment following accreditation takes place in the form of 6 monthly accompanied ward visits where at least 1 MR is observed each time In-house training and accreditation Read MR policy Candidate observes 10 MR Candidate is observed completing at least 10 MR receiving feed back Complete questions and answers in MR accreditation pack uccessfully pass 6 assessed Meds Rec After accredited has 6 monthly accompanied ward visit Fast tracked training and accreditation (when employing new staff accredited elsewhere) Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 89

90 Medicines Use and afety Read MR policy Candidate observes 5 MR Candidate is observed completing at least 2 MR receiving feed back Complete questions and answers in MR accreditation pack uccessfully pass 3 assessed Meds Rec After accredited has 6 monthly accompanied ward visit Resources Junior Drs Training Resources Tips for conducting Medicines Reconciliation Junior Drs: May%2015.pdf Junior Dr MR Training lides: May%2015.pdf Newly Employed Pharmacists Resources Accreditation for newly started Pharmacists training programme: 20training%20programme_Nov%2013.pdf ubstantive Pharmacy taff Resources Pharmacy Department CPD Medicines Reconciliation Presentation: Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 90

91 Medicines Use and afety liation%20presentation_may%2015.pdf Medicines Management Technician Training Resources MMT MR Accreditation Programme: df Fast-tracked accreditation programme for experienced technicians undertaking Medicines Reconciliation: MMT MR Accreditation Checklist: Organisation: Lewisham and Greenwich NH Trust Key Contact: Richard Pudney on Overview: The programme supports the development of the underpinning knowledge and practical skills to deliver Level 2 Medicines Reconciliation and includes a competency assessment for pre-registration Pharmacists. The key elements of the programme are delivered over a 4 week period using the following materials: Trainee and trainer documents. These provide case scenarios and the information to complete the competency assessments as well as underpinning knowledge and skills. A group session lesson plan to support completion of the programme. Mentoring/shadowing of MR delivery followed by delivery by the learner under observation with a summative assessment using documentation in the competency training document. The documents available via the links below are for pre-registration Pharmacists but can be applied to other staff groups. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 91

92 Medicines Use and afety Comments: trengths: There is practical evidence collecting, which fits in with pre-registration Pharmacist competencies and gives some practical experience under supervision. The programme is fully comprehensive and builds in a competency-based assessment. Use of a generic MR training template package ensures that the programme covers all the essential requirements, incorporating local practice and is less time consuming than developing it from scratch. Weaknesses Competency-based training is time-consuming to deliver. Initial training session is still classroom based. Use of a formal session means that individual learners may need to await session delivery before commencing the training programme as the training works best as groups being able to discuss ideas (i.e. it is trainee cohort dependent). Resources Medicines Reconciliation Training ession - Pre-registration Pharmacist Training (Trainer Copy): py)_ept%2014.pdf Medicines Reconciliation Training ession - Pre-registration Pharmacist Training (tudent Copy): opy)_ept%2014.pdf 5.4 Consultation kills in Medicines Reconciliation Any training or competency development surrounding MR should consider including or signposting practitioners to materials that support the development of good consultation skills as this is one of the key skills underpinning MR. The table below signposts to education and training materials and other tools that support the development of good consultation skills. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 92

93 Medicines Use and afety Table 5.4: Consultation skills training resources Training or Educational Resource Provider Centre for Pharmacy Postgraduate Education - Consultation skills for Pharmacy practice: taking a patient-centred approach RP Consultation kills Assessment tool and guidance Consultation skills for Pharmacy practice website Barbara s story Barnett N, Jubraj B, Varia (2013). Medicines adherence- are we asking the right questions and taking the best approach? Pharmaceutical Journal 2013;(291): Description of Training or Educational Resource Distance Learning programme This reflective tool and guidance can be used to support the development of your consultation behaviours and skills, and particularly helps you to develop and demonstrate competencies in cluster 1 of the FPF Patient and Pharmaceutical Care. This tool provides a structured approach to reviewing a patient s medicines to identify any problems they may have, including how the patient adheres to their treatment. This Consultation skills for Pharmacy practice website supports you through a learning pathway, as you develop and improve your patient consultation skills. The website forms part of a national training and development programme, created in response to the Modernising Pharmacy Careers (MPC) Created by nurses at Guy's and t Thomas' to raise awareness of dementia among staff, Barbara's tory is a series of 6 films which has changed attitudes to dementia in hospitals across the world. Explains how principles of health coaching can facilitate a shift from a product focused towards a patient centred approach Emphasises the need to adopt the Ask Don t Tell Habit Illustrates how to truly acknowledge the patient as an equal expert Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 93

94 Medicines Use and afety Consultation kills for Pharmacy Practice: Practice tandards for England These practice standards have been prepared as part of the modernising Pharmacy Careers programme to define the knowledge, skills and behaviours and attitudes that Pharmacy professionals should be able to demonstrate when communicating and consulting with patients Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 94

95 Medicines Use and afety Chapter 6 Quality Improvement Methodology and Medicines Reconciliation (Authored by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North West London (NWL) This chapter aims to provide an introduction to quality improvement methodology with some guidance and tools that will allow individuals and organisations to consider how they may improve the quality of the Medicines Reconciliation process within their own organisation. 6.1 The Process of Quality Improvement The process of quality improvement has several stages, which can be visualised in fig The cycle for improvement 1. Fig 6.1.1: The Cycle for Improvement (reproduced with permission from the authors 1 ) When this cycle is successfully completed, improvements to patient care and health or population outcomes should be observed. Each step of the cycle is described more clearly below: 1. What Actually Happens: What Actually Happens: It is important to focus on the reality of current care delivery in a particular care setting; considers patient experience, outcomes as well as service delivery. This should be considered at the beginning of the process to understand what Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 95

96 Medicines Use and afety is happening before improvement work is planned, and revisited as changes are being implemented to ensure that they are making the desired difference. 2. Identify Needs: By understanding the current situation, it is possible to identify areas for improvement, for instance unmet needs, problems, variations and quality issues. 3. Identify Priorities: It is necessary to prioritise resource investment drawing on knowledge including patient and population needs, economic and clinical considerations to focus energy and support successfully delivery of improvements. 4. Identify Potential olutions: Identifying potential solutions that need to be implemented and tested to see if they are capable of improving what actually happens. This stage considers existing knowledge and interventions or creates new interventions and evidence about what might work. 5. Implement: Process by which potential solutions are implemented into practice. This is an iterative process changing in response to emerging evidence to ensure solutions are fit for purpose and deliver the desired change in what actually happens. In reality there is often a gap between the identification of potential solutions and their implementation and delivery of improvements in care settings. This gap is often described as the translational gap and results in poor quality patient care. Fig describes a quality improvement project which had a significant focus on Medicines Reconciliation that took place at Chelsea and Westminster Hospital and the challenges the team had to overcome to achieve their desired improvements. Fig 6.1.2: A project to implement medicines optimisation to support patients with changes made to medication during an emergency admission into hospital. A project team was established to address concerns re medicines optimisation including reconciliation. To start, the project team mapped the actual process of a patient s journey through the hospital to discharge home and how this related to their medication needs. They discovered that four separate professionals were taking medication history from patients (doctors, nurses, pharmacists and physiotherapists) and that this information was being held in silos and not shared with the rest of the team. The process map showed inefficiencies, poor patient experience and safety hazards: For example one patient had arthritis and the physiotherapist was aware she was unable to open bottles with a child-proof top, but she was given tablets in a bottle with a child-proof top from pharmacy. The project team facilitated a number of activities to support staff and patients to redesign the process, renegotiating the roles of each of the four staff groups so work was coordinated more effectively. As a result of this work a single Medicines Reconciliation form was introduced for use by all four professional groups. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 96

97 Medicines Use and afety The team started collecting data on how well the new Medicines Reconciliation process was working, including the rate of errors in the reconciliation process. They found that there was a high rate of errors (24%), although the error rate varied a lot, between 0% and 74%. The team realised that whilst they had improved the process for Medicines Reconciliation they still needed to improve the rate of error free Medicines Reconciliation and further reduce variation in how the process was completed. The team investigated the causes of high or low error rate and how error rates related to patient flow and staffing levels. As a consequence of this investigation they decided to redistribute Pharmacy staff to support a 7 day per week to improve consistency of their service. The team had to negotiate this with several people including the executive team to secure the appropriate budget and permissions for this change to take place. The team realised that information availability on patient level drug history was a systemic problem, and whilst this hadn't been the original focus of the project, it was fundamentally linked to their ability to complete high quality Medicines Reconciliation. Patients involved with the project challenged assumptions about relying on clinicians and healthcare organisations for this information. To support patients to have greater ownership of their medication histories the team worked with patients to develop a patient-held My Medications Passport that could act as information source to support Medicines Reconciliation. This led to patients using the My Medications Passport as a platform for conversations with health care professionals about their drug histories. The team also worked to increase their profile, identifying how their work related to key hospital concerns including the importance of Medicines Reconciliation to admissions avoidance, how it linked to the safe and effective flow of patients through emergency care, and how it contributed costsavings by avoiding inappropriate prescribing. Aligning the project to that of the key hospital concerns took considerable work, but helped to secure vital resources including executive support to champion the work and permission for team members to be released from daily business. This example highlights the complexities the project team had to navigate and the wider range of issues they encountered right from what actually was happening on the wards, identifying the need for change, identifying priorities and solutions and implementing improvement initiatives. (cycle for improvement model 2 ). The example also illustrates why effective implementation of new evidence requires a deep understanding of complex care processes and how they interrelate to form a care delivery system. For further information contact Vanessa Marvin at Vanessa.Marvin@chelwest.nhs.uk Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 97

98 Medicines Use and afety 6.2 A ystematic Approach to Quality Improvement: CLAHRC NWL has developed a systematic approach to quality improvement based on a wide range of existing research evidence and their experience of delivering, evaluating and researching improvement projects over the last six years and draws on a diverse set of principles from academic literature 2-6. The methods draw on research literature including basic scientific research, clinical research, statistics, change management, leadership, and improvement science. Each of the methods helps teams to addresses a different challenge and using these together will help navigate and make sense of complexity, incorporate evidence into local practices, overcome barriers and obstacles to change and maximise the success of the quality improvement project. The approach to quality improvement is detailed in a stepwise manner table 6.2. Table 6.2: Quality Improvement Methodology and Tools 1. Representative Team 2. Patient and Public Involvement 3. takeholder Management 4. Process Mapping 5. Action Effect Method 6. Plan-Do-tudy-Act cycles 7. Measurement for Improvement (including tatistical Process Control) 8. Outcome Measurement 9. ustainability Model 10. Reviews 11. Finances Representative Team: What is a representative team? In order for the research to be embedded into practice, it is essential to include front line staff members involved in the day to day 'operational systems' that deliver patient care. To achieve patient centred care, it is also important to actively involve patients, families and carers who are likely affected by the research throughout the life of the project. Why have a representative team within a quality improvement project? uccessful projects are led by strong individuals who are committed to making a difference in bringing high quality and safer care to patients. It helps to have representation from all staff groups affected by the project as they can bring insights from their professional perspectives and influence their peers. The core team will provide oversight and the driving force for the work to proceed. It should be remembered that they will also need to engage with a wide range of stakeholders (see Patient and Public Involvement and takeholder engagement sections below). Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 98

99 Medicines Use and afety How to choose a representative team? Involve people who are in key roles that have led successful projects and programmes within your organisation. Highlight the opportunities for professional development when engaging frontline staff and define clear roles, responsibilities and time commitments with colleagues and their line managers and develop a rota for meetings and events to help maintain project momentum. Example: ponsor - Ensures the project is in line with the organisational strategies and can support key decisions necessary to move the project forward. The more complex the project is the more involved your executive sponsor should be. (e.g. Chief Pharmacist, Medical Director, Nursing Director) Clinical Leads - The clinical champion for the project who coordinates the delivery of the improvement whilst maintaining high governance standards. (e.g. enior Clinical Pharmacist, Care of the Elderly Consultant) Project Managers - upport the clinical lead and project team members in managing timelines and coordinating actions, applying improvement methods and the overall delivery of the project. (E.g. mid-career pharmacist, managers, external project support). Information upport - Key to collecting routine data and reporting on it. Early collaboration with Information Technology and Information ervices and other relevant departments will support system changes. (e.g. information analysts, business managers, researchers) Ward Nursing taff Nurses as part of the multi-disciplinary team support the implementation of the improvement activity, collect and analyse data and support the delivery of the project to improve patient care (Nurses may be collecting MR data for Med afety Thermometer already) Ward Pharmacy taff - Pharmacists as part of the multi-disciplinary team will support the project in implementation, providing information on the process and flow and support iterative changes that need to be implemented as well supporting in data collection and analysis. Medical taff, AHPs, receptionists, ward clerks and other healthcare staff may be key people in bringing your improvement project into practice. Engaging these members from the beginning will make them feel involved and empowered to make change, and bring useful insights to guide project direction. Patient and Public Involvement: What is Patient and Public Involvement? The term Patient and Public Involvement is to mean activities carried out with or by members of the public rather than to, about or for them. Individuals can be considered as Patients or Public if they are: patients; potential patients; informal or family carers; people who use health and social care services; community and voluntary sector groups or individuals. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 99

100 Medicines Use and afety Why involve patients and the public? People have a right as citizens and taxpayers, to be involved in shaping services. However, more importantly involving patients can be transformative and a useful challenge to existing ways of working 7. Working with patients/public can lead to tangible benefits in healthcare improvement as well as unexpected benefits Involvement can be at the individual or collective levels that is, an individual may be involved as a result of their own care or involvement can be with groups of people to inform decisions for example at service level. Whether the project team should engage individually or collectively, should be decided by what the aims are of the quality improvement project. How to involve patients and the public? How people are involved in any project needs to be specific to the context. Thinking carefully about the rationale for patient involvement, identifying the most appropriate methods to use, having clarity on the role(s) patients will play and ensuring that effective involvement strategies are in place, are important steps towards facilitating the involvement of patients in ways that harness its full potential, and the distinctive roles that patients can play in improvement work. It would also be beneficial to reflect on the experience and expertise across the project team when involving patients and the availability of resources to support specific methods for example workshops and focus groups. For example, patients and the public can be involved in emotional mapping of patient journey to understand their perspective of care or can be involved as part of the project team. Example: Patients were part of an improvement team aiming to improve prescribing in the elderly. Interactions that the patients had in other healthcare settings as well as in their capacities as carers or people with long-term conditions, led them to suggest a passport which would contain all of their current medication information and would support communication with healthcare professionals. Healthcare professionals worked with patients as team members and together developed this idea in to a My Medication Passport 13. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 100

101 Medicines Use and afety takeholder Engagement: What is takeholder Engagement? takeholders are individuals, groups, departments and organisations that can influence success and/or will be impacted by it and they may be instrumental in highlighting new developments that may have a positive or negative affect on the quality improvement project. takeholders could include patients, clinicians, executives, managers, non-clinical staff, commissioners, local authorities, community and voluntary organisations and regulators, for example the Care Quality Commission. ome stakeholders will have more influence and interest than others. Identifying who they are will help understand how to evoke their interest, gain their support and meet their needs. It is necessary to map, communicate and engage with stakeholders continuously through the life of the project. Why do stakeholder mapping? To enhance the success, sustainability and spread of the quality improvement project it is important for to identify and involve key stakeholders outside of the immediate setting at an early stage of project development. Consider: How can they be involved? What stage might you involve them? What do you aim to achieve through their involvement? How to engage with stakeholders? Initially it is important to scope widely to seek out potential useful influence, interest and commitment. takeholders can be identified by thinking carefully about the purpose of the project, what the aims are of the project and who can influence its success. This can be supported by completing a two-by-two matrix (Fig 6.2.1) identifying key stakeholders along a continuum of interest on one axis and influence on the other. The four quadrants within the stakeholder map informs how each stakeholder should be managed. Fig 6.2.1: takeholder Mapping Quadrant Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 101

102 Medicines Use and afety Example: In a quality improvement project focussed on Medicines Optimisation at Chelsea Westminster Hospital the team undertook a stakeholder mapping exercise and started with the example below. They soon realised that they had not included Physiotherapists and Allied health prescribers within the project and also realised they needed support from the Chief Pharmacist. They then updated the stakeholder map to include others who needed to be involved and informed in the project. Process Mapping: What is Process mapping? A process map is a visual representation (a picture or model) that shows all of the current steps in a process. In a healthcare context, this is often a map of a patient journey - highlighting the relevant procedures and administrative processes a patient might come across from point A to point B in their treatment. Importantly the process map should show how things are and what currently happens, rather than what should happen or what people would like to happen in the future Why use process mapping? Process mapping helps users to see what is happening by giving a structured, visual method of representing tasks and decisions made within a clearly defined context. etting out a process visually like this helps anyone involved in the quality improvement project to see other people's tasks and roles. Process mapping identifies opportunities for improvement towards a more safe, efficient and coordinated process for patients and staff. It can also help to diagnose problems and identify areas for improvement. This is necessary to influence how the project will align or fit into these systems and roles to sustain and embed good practice, and should be revisit as the project progresses and changes are made. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 102

103 Medicines Use and afety How to do a process map? The most effective approach to building a process map is to work collaboratively as a project group. The more people that work on the map, the more likely you are to capture the entire process accurately and from all perspectives. To understand the process, team members must walk through the patient journey from beginning to end to find out what is actually happening, not what is perceived to be happening? Outlined below are some tips when conducting a process mapping exercise: Allow as much time as possible to gather the team and stakeholders together Planning and preparation for this event is key Decide who can facilitate and ask the challenging questions that will not disrupt the dynamics. Premeet with senior leaders and managers to discuss your project and invite them to come along to the process mapping session. It is important to agree the starting point and end point of your pathway and what is in scope and out of scope tart at a high level and drill down Identify and discuss at each step who is involved in that process or decision point? What are the parallel processes? Where are the potential trigger points that could support your project? Park issues you cannot solve, to be returned to at a later date. Be open to ideas and generated by the session. Document ideas for future use There may be a need to return to complete more information later that is not available at the initial time of doing the map. It is helpful to observe the processes in practice once the initial map has been developed to see if it accurately reflects what is actually happening in the care setting. It can be helpful to revisit the process map throughout the improvement project to see if changes are having the desired impact and to assess any further learning or problems that emerge as changes are made. The session will help identify which areas along the pathway require improvement or how they will be affected by introducing a change. The session will also help the development of key measures, and identify who is involved in the care processes which may indicate additional people to join the project team or new stakeholders to engage. The session may identify areas where it is unclear what the process is and where further investigation needs to take place; for example in collecting data (observation, speaking to colleagues, quantitative data). Example: ee Fig and Fig in chapter 2 for an initial flow chart of the Medicines Reconciliation process which will support a process mapping exercise. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 103

104 Medicines Use and afety Action Effect Method (AEM): What is Action Effect Method? The Action Effect Method 14 is a structured way to develop a shared understanding and visual representation of the three questions in the model for improvement: (1) hared aim: What are we trying to accomplish? (2) Measurement: How do we know that a change is an improvement? (3) Intervention Ideas: What changes can we make that will result in an improvement? The Action Effect Method specifies a method of developing the shared aim, then breaking this down into well-defined contributing factors and connecting these to interventions through cause/effect chains. The Action Effect Method produces a visual representation known as an Action Effect Diagram, which depicts the overall aim in a box on the left, and interventions and implementation activities on the right. The Action Effect Diagram helps you visualise a cause/effect pathway, connected by arrows, from these interventions to the overall aim. Measurement concepts and links to the evidence are depicted visually on the diagram as well. This helps the entire project team to keep the whole picture of the project in mind, and focus on the overall aim, whilst planning specific tasks and implementation efforts. Why use the Action Effect Method? The Action Effect Method gives you a clear and structured way to uncover the detail of your project processes. The finished Action Effect Diagram demonstrates how an overall aim might be achieved by reading left to right, and why an intervention is being tested by reading right to left. It can help team members and other stakeholders to see exactly what is going on in your improvement project. It also makes sure everyone is focussed on a common aim and help team members to communicate clearly to others about your project. Interventions are also identified that can be trialled using Plan-Do tudy- Act cycles and predictions made about the potential impact of interventions and how this can be directly and indirectly measured to assess change efforts success. How to construct an Action Effect Diagram? It is helpful to have an initial facilitated session that brings together diverse stakeholders. While taking time to consider the project in detail is preferable, if needed to, the project team could create an Action Effect Diagram within a two-hour facilitated session. The initial Action Effect Diagram can then be built on and developed further over time as the project progresses. The steps below provide some tips on how to facilitate a session: et the scene: Explore the patient and carer experience by using emotional mapping to help remind stakeholders why this work is important and focus their thinking on what changes need to take place. Agree the project aim: Establish a common purpose and shared aim by discussion. Always start with exploring the overall aim of different people in the group what do you want to achieve? This is essential to ensure that the whole team are in agreement, and to ensure that the discussion focuses on the main issue. Try and steer conversations away from ideas for interventions during Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 104

105 Medicines Use and afety this stage as this can lead to the thought process being constrained by pre-existing ideas for interventions or can create divisions in opinion. Use this time as an opportunity to think about your project from other perspectives including those of patients to clarify why it is important and what you want to achieve together. Identify component factors: Discuss the aim in more detail, identify top-level major contributing factors (the areas that will have the biggest impact on achieving your aim) and then break down major contributing factors into contributing factors. Once an aim has been agreed, teams could use a brainstorming session to help collect and discuss ideas for major contributing factors and the cause and effect relationships that exist between them, before structuring the results into the format of an action effect diagram. Process mapping will help the team identify ideas for major contributing factors and key elements by considering the patient journey from different perspectives. Only start thinking about potential interventions once the aim and contributing factors columns of the action effect diagram are agreed by the team. Using the Action Effect Diagram: Once developed the Action Effect Diagram can be shared with stakeholders to communicate why any changes need to take place or to gain support and engagement. In order to understand the impact your interventions are having measures can be assigned to the cause and effect chains in the Action Effect Diagram. Regular collection and review of this data can be used to answer the question How will we know that a change is an improvement? and can be used in the tudy part of Plan-Do-tudy-Act cycles. Example: Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 105

106 Medicines Use and afety Plan-Do-tudy-Act cycles: What is Plan-Do-tudy-Act cycles? The Plan Do-tudy Act cycle is a framework for an efficient trial and learning methodology (see fig of PDA cycle below). The cycle begins with a plan and ends with an action and the use of the word study emphasises that the purpose of this phase is to build new knowledge. Multiple Plan-Do- tudy-act cycles are usually needed to make successful changes. Fig 6.2.2: PDA Cycle Why use Plan-Do-tudy-Act cycles? The complexities of healthcare systems make it impossible to do all the design and planning of a change before it is put into practice. The PDA cycle 13 is a way of developing an intervention over time, testing changes by starting on a small scale, overcoming barriers that are encountered, and then gradually ramping up to a full scale intervention. By the time a full scale implementation is reached all the little unforeseen glitches will have been sorted out and there is a better chance of achieving the aims of the intervention and sustaining this in the long term. How to use Plan-Do-tudy-Act cycles: Testing begins with a well laid out plan (to test a change) developed with the project team. Part of starting any improvement project is to break it down into manageable small steps. These steps will be the basis for changes to test using Plan-Do-tudy-Act cycles. It is important to prioritise changes and conduct them one at a time: which will provide the biggest impact? From the previous example of the Action Effect Diagram, the testing would be linked to each the identified interventions on the far right hand side of the action effect diagram for example the design of a new form for medication review. Plan: The plan should include predictions made by the project team. Identify potential changes to test and discuss as a team what predictions will happen because of this change and any difficulties that are anticipated. Document these to compare back to after your test. Do: The project team then carries out the agreed plan based on who does what, when and where as identified in the plan and collect data for analysis. Improving the Quality of Medicines Reconciliation: A Best Practice Resource and Toolkit: Version 1 June 2015 (C) 106