Clinical Medicines Reconciliation: Standard Operating Procedure Document Control Summary Status: Version: Author/Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Replacement (policy converted to procedure) 4.1 Date: February 2016 Mo Azar, Deputy Director of Pharmacy Policy and Procedures Committee Date: 18/02/2016 Policy and Procedures Committee Date: 18/02/2016 Medicines Optimisation Strategy 2013-2018: Making the Most of Medicines February 2016 (initially in place from June 2014) January 2017 medicines, reconciliation, admission, discharge, community, right, correct, discrepancy, sources, history, prescribing, prescription Medicines Code Trust Formulary Contents 1. Introduction... 3 2. Purpose... 3 3. Scope... 3 4. Approaches to Medicines Reconciliation... 4 5. Process for Monitoring Compliance and Effectiveness... 5 6. References... 5 Appendix 1... 6 Appendix 2... 7
Change Control Amendment History Version Dates Amendments 4.1 February 2016 Converted to procedure and new template. EPMA aspects removed as not currently in place. 2
1. Introduction Medicines Reconciliation is defined by the Institute for Healthcare Improvement (IHI) as the process of obtaining an up-to-date and accurate medication list that has been compared to the most recently available information and has documented any: discrepancies changes deletions additions resulting in: a complete list of medications, accurately communicated. 2. Purpose The purpose of medicines reconciliation is to: make sure the right patient gets the right drug, in the right dose and at the right time (i.e. continuity of treatment) reduce the risk of medication errors occurring when the care of a patient is passed from one care setting to another provide ongoing personalised pharmaceutical care for each patient reduce confusion about patients medication regimens (for both healthcare professionals as well as for service users and carers) improve service efficiency and make the best use of staff skills and time In addition, medicines reconciliation makes the process of monitoring ongoing treatment easier. 3. Scope This SOP applies to all prescribers of all grades who admit service users to inpatient settings. The responsibility for accurate and complete medicines reconciliation remains with the prescriber, although other staff may support the process. The consultant should oversee that the medicines reconciliation process is robust for patients under their care. Nursing staff, pharmacists and pharmacy technicians also have an important role in the medicines reconciliation process which is complementary to the work of the prescriber. The SOP also covers referral into community teams and is not restricted to mental health services. Consideration should also be given at the point of discharge to those in other organisations who may rely on the information provided by this Trust in order to undertake their own medicines reconciliation. The risks posed to service users by poor reconciliation of prescribed medicines after leaving our care is just as critical as those posed by poor reconciliation on admission. Service users, carers and healthcare professionals from other organisations should all be included in the fact finding undertaken as part of medicines reconciliation. Confidentiality must be maintained however, and not all family members will be aware of the treatments prescribed to their relative and the wishes of the service user should be respected. This procedure should be read in conjunction with all Medicines Optimisation Policies, particularly the Medicines Code and the Trust Formulary. 3
4. Approaches to Medicines Reconciliation Medicines reconciliation can be considered in two discreet stages: Basic reconciliation / clerking in (Stage 1): Basic medicines reconciliation involves the collection and accurate identification of a patient s current list of medicines. An example of basic medicines reconciliation would include medication history-taking in secondary care, where a complete and accurate list of a patient s current medication regimen is documented on admission. It should be completed as accurately as possible, at the point of admission. Useful sources that can be accessed out-of-hours include the Summary Care Record (accessed through the RiO Clinical System) and any Patient s Own Drugs which may have been brought in by the service user, family or key worker. When service users are admitted to hospital they are often at their most vulnerable and are not always able to contribute accurately to a medication history-taking discussion. It is suggested that the minimum dataset of information available on admission to hospital should include: Complete patient details i.e. full name, date of birth, weight (if under 16 years), NHS number, GP, date of admission The presenting condition plus co-morbidities A list of all the medicines currently prescribed for the patient, including those bought over-the-counter (where this is known) Dose, frequency, formulation and route of all the medicines listed An indication of any medicines that are not intended to be continued Known allergies, sensitivities and previous drug interactions Full reconciliation (Stage 2): Full medicines reconciliation builds on Stage 1 of the process and involves taking the basic reconciliation information, comparing it to the list of medicines that was most recently available for that patient. In addition, it involves identifying any discrepancies between the two lists and then acting on that information accordingly. In other words, interpreting the outcome of the basic reconciliation in light of a patient s ongoing care plan; resolving any discrepancies and accurately recording the outcome. Medicines Reconciliation on Admission Stage 1 must be completed as soon as possible from the point of admission for inpatients, in all service areas, usually, by junior doctors or suitably experienced Independent Non-Medical Prescribers. On-call doctors should attempt to complete Stage 1 when admitting a service user though it is accepted that it may not be possible to contact other organisations. The Summary Care Record (available through the RiO clinical system) may be a useful source out-of-hours provided GPs and service users have not opted out of the system. Stage 2 should be completed within 48 hours after admission. Appropriate healthcare professionals who can undertake Stage 2 include those identified in Stage 1 as well as pharmacists, pharmacy technicians and ward nurses. This can be through checking against a secondary source and highlight any discrepancies for example. A doctor or suitably qualified Independent Non-Medical Prescriber (working within their scope of practice) must act on any discrepancies identified and 4
resolve them. This requires clinical judgement on the options available; i.e. it may not be appropriate to just write up the GP record if different to what the service user is claiming (and vice versa). Pharmacist and pharmacy technician involvement is encouraged in the medicines reconciliation process in every clinical area. Where clinical pharmacy support is available, pharmacy staff may be involved in medicines reconciliation as soon as possible after admission (as recommended by the National Institute for Health and Care Excellence). The minimum dataset of information (see above) available on admission to hospital should be obtained from the referring health service (e.g. GP practice, crisis team). When the Crisis Resolution/Home Treatment Team is involved in the admission of a patient, it is their responsibility to obtain the current medication report from the GP in working hours, or collect the patient s medication from their home at other times. Standard documentation is used to collect and document information about current medication. The key place to document completion of medicines reconciliation on admission to inpatient areas is on the front of the Medicines Treatment and Record Sheet (medicines card). Appendix 1 highlights the area to be completed. Sources of information about patients medicines should be up-to-date, and verified. The likely reliability of the source of information should be considered, and then the priority for verification applied appropriately (for guidance, see Appendix 2). Medicines Reconciliation on Referral to a Trust Community Service Medicines reconciliation is equally important at all interfaces of care. When a service user is referred to a Trust community service (not limited to Mental Health services), the team should obtain information about the service user s current medication from the GP at the time the referral is accepted. 5. Process for Monitoring Compliance and Effectiveness The inpatient clinical pharmacists will support their teams compliance with this procedure through the training of junior doctors at induction and day-to-day activity on the wards. They will, alongside their pharmacy technician colleagues, support the ward team by reviewing the medicine card against the sources available, accessing the Summary Care Record and assessing the suitability of any Patient s Own Drugs (PODs) that may have been brought in with the service user. Pharmacy staff who identify any discrepancies will seek to intervene at the earliest opportunity with the prescriber so that any confusion is cleared promptly. The Pharmacy and Medicines Optimisation Department also undertakes regular audits on the safe and secure handling of medicines. A spot check of medicines reconciliation is included on the inpatient version. The Medicines Optimisation Committee scrutinises the results of these audits and confirms any remedial actions. 6. References Medicines Reconciliation to Prevent Adverse Drug Deaths, Institute for Healthcare Improvement. www.ihi.org accessed February 2016 Transition between inpatient hospital settings and community or care home settings for adults with social care needs, NICE guidelines [NG27]. National Institute of Health and Care Excellence, December 2015 5
Appendix 1 Documentation of Medicines Reconciliation Medicines reconciliation is deemed completed only when the section of the Medicine Treatment and Record Sheet s front cover is filled out. Both sources should be documented (signed and dated), cross checked and matched (signed and dated), and if any discrepancies were identified that they have been resolved (signed and dated). It is the prescriber s responsibility to sign that the cross checking and resolution of any discrepancies has been completed. Discrepancies should not be left unresolved. NB: This only needs completing on the first medicines card on any admission. Subsequent cards need only refer to the initial card; however, they should still be verified against the previously completed medicines card to avoid transcription errors. 6
Appendix 2 Sources of Information for Medicines Reconciliation There are many potential sources of information detailing service users medicines although no source is reliable unless it is up-to-date. No source should be considered perfect by itself and should always be compared with another source. In every case, the source of information should be documented, dated and, where practicable, verified. More reliable sources: A recent print-out from a GP computer system: although this should be verified with the patient where possible to ensure that the service user is in fact taking all of the medicines listed and at the stated dose. They should also be asked about any overthe-counter, herbal, or non-prescribed medicines or remedies otherwise acquired. NB there is a risk that medicines which are not prescribed by the GP may not be included in their clinical record system. This might include those medicines issued from hospital-based clinics, such as clozapine, long acting antipsychotic injections, anticoagulants, treatments for HIV or oncology, unlicensed medicines, and clinical trial medication; or from other prescribers whose care they may be under. Medicines included in shared care arrangements, e.g. methotrexate, may not be included in a GP computer print-out or Summary Care Record. Repeat prescription tear-off slips: the date of printing should be checked and the list verified by the service user (or carer) where possible. Remember that seasonal products (e.g. hay-fever medication) and one-off prescription items (e.g. antibiotics) may not appear on the list of current medicines. Patient s own drugs (PODs): often brought in by service users at the request of the hospital and in-line with locally agreed procedures for the re-use of patient s own medicines. Information gathered in this way may not be complete, for example, service users may not bring oral contraceptives, topical, or inhaled preparations in with them since they often do not class these items as medicines. Remember also that service users may not remember to bring in fridge items or bulky medicines. The items should be checked thoroughly to ensure they are still in date, appear to be in an acceptable condition and are in fact dispensed to the actual service user; i.e. they are not intended for a different family member. Patients and/or their carers: as service users/carers become better informed about their condition, their knowledge of the medicines that they take will also tend to increase. However, even though they may be considered a more reliable source of information about the medicines that they are actually taking, pronunciation of medicine names and medical terms may not always be accurate and could lead to confusion. Furthermore, caution should be used regarding medicines liable to misuse (such as benzodiazepines and opioids) where there may be an attempt to request more than actually prescribed. Risks may arise if a higher dose than they are actually used to is prescribed in hospital since the service user may have been diverting the medication for onward supply; risks may also arise if a lower dose than they are actually used to is prescribed in hospital since an unexpected withdrawal may be precipitated. Take-home prescription summaries/hospital notes: if a service user has had a recent admission to hospital then the take-home summary, discharge prescription or hospital notes should be reliable. However, if the date of discharge is more than four weeks past, then the service user s GP will need to be contacted in case any amendments have since been made. NB outpatient medication records may be less comprehensive than inpatient records. Discharge summaries often omit medicines not initiated during the hospital admission. The Insulin Passport : This is a record of a service user s current insulin products. It provides an additional check for insulin-dependent diabetics, since the current dose 7
requirements are not usually stated on the repeat medication summary. Where there is a discrepancy between the Insulin Passport, their clinical notes or current understanding of insulin therapy by the team, it should be reconciled and the information in the Insulin Passport updated. The Summary Care Record: This can be viewed from the Health and Social Care Record on RiO and provides the current medication as detailed on the GP computer system. This is particularly useful out-of-hours, where service users and GP practices have consented to share information. This information should still be verified with the service user to ensure that they are in fact taking all of the medicines listed and that they are not taking any over-the-counter, herbal, or non-prescribed medicines or remedies otherwise acquired. NB there is a risk that medicines that are not prescribed by the GP may not be included. This might include those medicines issued from hospital-based clinics, such as clozapine, long acting antipsychotic injections, anticoagulants, treatments for HIV or oncology, unlicensed medicines and clinical trial medication; or from other prescribers whose care they may be under. Less reliable sources (usually need additional verification): MAR charts (Medication Administration Records) from social and care home settings. Although these are official documents, they may not have been reconciled with GP medication records. Community Pharmacy Patient Medication Records (PMR), repeat dispensing records and Medicines Use Review (MUR) records. Community pharmacists do not routinely have access to GP medication records so PMR and MUR records may be incomplete. Repeat dispensing records may not include recently prescribed acute or when required medicines. Specialist nurse care plans (including mental health) and clinical management plans for Supplementary Non-Medical Prescribers; however they may not contain all of the medicines that a service user is prescribed. Care home managers who may be able to provide medicines details out-of-hours. Single Assessment Process documentation (SAPs) or Care Programme Approach (CPA) documentation (may be incomplete or not up-to-date). Message in a bottle : a voluntary scheme co-ordinated by the Lions Club of Great Britain and supported by various NHS organisations. A plastic canister containing a variety of essential information is kept in a service user s fridge and can be readily accessed by emergency service teams should the patient need to be admitted to hospital in an emergency. The information held in these canisters may include information on medicines, but this may be out-of-date, and may not include all of the medicines that a service user is taking. Monitored Dosage Systems (MDS) and other compliance aids: although these systems are usually issued with some sort of written record of the medicines they contain, that information can easily become detached from the container and it would be impossible to reliably identify every tablet in the system. In addition, many tablets and capsules, and of course topical and liquid preparations, are unsuitable for inclusion in the MDS container. Clinical trial/unlicensed medicines may not be labelled with the name of the medicine; the issuing hospital pharmacy and/or the Principal Investigator would need to be contacted for further information. Sources that would require further investigation: Social work teams Drugs team/alcohol detox units those these must be contacted to confirm prescription details for methadone and buprenorphine substitution programmes Prison service/probation officers Department of Work and Pensions 8
Schools Homecare providers Anticoagulant clinics Walk-in centres Family and friends NB service users may not wish them to be contacted and they may not be aware that their relative is receiving medical care. The service user s views and right to confidentiality should be followed Private healthcare providers Private healthcare insurers Although occasionally these sources may need to be contacted, this should be as a last resort because they would rarely include all of the medication that a patient is taking and are unlikely to be up-to-date. 9