PROCEDURE FOR MEDICINES RECONCILIATION BY NURSING STAFF FOR PATIENTS ADMITTED TO THE COMMUNITY HOSPITALS OUT OF HOURS Policy Details NHFT document reference MMPr030 Version 22/02/16 Date Ratified May 2016 Ratified by Medicines Management Committee Implementation Date May 2016 Responsible Director Medical Director Review Date May 2018 Related Policies & other documents MMP001 Control of Medicines Policy, MMPr008 Controlled Drugs Procedure, MMP013Medicines Reconciliation Procedure, MMPr014 Procedure for the Handling of Patient s Own Medication Freedom of Information category Procedure 1 of 11 Implementation Date: May 2016
TABLE OF CONTENTS 1. DOCUMENT CONTROL SUMMARY... 3 2. INTRODUCTION... 4 3. PURPOSE... 4 4. DEFINITIONS... 4 5. DUTIES... 4 5.1. Chief Executive... 4 5.2. Medical Director... 5 5.3. Medicines Management Committee... 5 5.4. Appointed Practitioner in Charge of the Ward... 5 5.5. Nursing staff... 5 5.6. Medical Staff... 5 6. PROCESS... 5 6.1. Transfer during working hours... 5 6.2. Transfer out of hours... 5 6.3. Medicines Reconciliation by Nursing Staff... 6 6.4. Patient s Own Drug Assessment... 7 6.5. Recording of Administration of Medication... 7 7. TRAINING... 7 7.1. Mandatory Training... 7 7.2. Specific Training not covered by Mandatory Training... 8 8. MONITORING COMPLIANCE WITH THIS DOCUMENT... 8 9. REFERENCES AND BIBLIOGRAPHY... 8 10. RELATED TRUST POLICY... 8 Appendix 1: Flowchart for the assessment of PODS... 9 Appendix 2: Out of Hours Request for Change in Medication... 10 Appendix 3: Patient s Own Medicines Assessment and Reconciliation Form for the Community Hospitals... 11 2 of 11 Implementation Date: May 2016
1. DOCUMENT CONTROL SUMMARY Document Title Document Purpose (executive brief) Status: - New / Update/ Review Areas affected by the policy Policy originators/authors Consultation and Communication with Stakeholders including public and patient group involvement Procedure for Medicines Reconciliation by Nursing Staff for Patients Admitted to the Community Hospitals Out of Hours To inform this staff group of the correct procedures so that the correct medication is administered to the correct patient, in the correct form, by the correct route, at the correct dose, at the correct time. New All community hospital inpatient areas Kelly Pritchard Russell Parsons Rita Reeves Bharath Lakkappa Medicines Management Committee Archiving Arrangements and register of documents Equality Analysis (including Mental Capacity Act 2007) Training Needs Analysis See section 7 Monitoring Compliance and See section 8 Effectiveness Meets national criteria with regard to NHSLA NICE NSF Mental Health Act CQC Other Further comments to be considered at the time of ratification for this policy (i.e. national policy, commissioning requirements, legislation) If this policy requires Trust Board ratification please provide specific details of requirements The Risk Management Team is responsible for the archiving of this policy and will hold archived copies on a central register See MMP001 Control of Medicines Policy 3 of 11 Implementation Date: May 2016
2. INTRODUCTION Medicines reconciliation should ensure that the medicines a patient receives on admission to hospital correspond to those that the patient was taking before their admission, unless there are sound clinical reasons to the contrary. Each patient should have his or her medication history taken and confirmed as soon as practical after admission to the ward. It recognised that out of hours there is often a delay in a patient having medicines reconciliation undertaken by a prescriber and then a subsequent delay in an NHFT drug chart being prescribed. This had led to omission or delay of medication in some circumstances. This procedure has been written to support the medicines reconciliation and administration of medication to patients who are transferred to community hospitals out of hours. 3. PURPOSE To inform nursing staff of the procedure for medicines reconciliation and assessment of medication out of hours so that the correct medicine is administered to the correct patient, in the correct form, by the correct route, at the correct dose at the correct time. 4. DEFINITIONS POD Patient s Own Drug. A POD is any medication prescribed for or purchased by a patient which is brought into the inpatient area with them on admission CD Controlled Drug TTO To take out prescription NHFT - rthamptonshire Healthcare NHS Foundation Trust NGH rthampton General Hospital KGH Kettering General Hospital 5. DUTIES 5.1. Chief Executive Has overall accountability for the safe and secure handling of medicines. 4 of 11 Implementation Date: May 2016
5.2. Medical Director Is the Board member with responsibility for the safe and secure handling of medicines and is the Accountable Officer for controlled drugs. The Medical Director is responsible for the dissemination of this procedure to their Clinical Directors and Clinical Tutors for onward dissemination to all medical staff 5.3. Medicines Management Committee Will approve and review these guidelines 5.4. Appointed Practitioner in Charge of the Ward Are responsible for the dissemination and implementation of the procedure in their service areas 5.5. Nursing staff Are responsible for: checking if a patient has brought medication (PODs) into the inpatient area assessing for suitability of reuse, and administering any PODs which will be used in line with MMPr014 Procedure for handling patients own medication and MMP001 - Control of Medicines Policy to act in accordance with this procedure to escalate any issues of concern to the senior nurse and medic on call. 5.6. Medical Staff Must ensure that medicines reconciliation is undertaken within 24 hours or as soon as is practically possible before medicines are prescribed on the NHFT drug chart as per MMPO13 Medicines Reconciliation Procedure. Ensuring that medication changes out of hours are communicated via the Out of Hours Change of Medication Form. 6. PROCESS 6.1. Transfer during working hours For new patients transferred during normal working hours, medicines reconciliation and generation of a NHFT prescription chart should be undertaken as soon as is practically possible by the medical staff as per the MMP013 Medicines Reconciliation Procedure. 6.2. Transfer out of hours If a patient is expected to be transferred to the community hospitals from another organisation it is reasonable to expect that the patient will be transferred with a valid Trust s prescription chart from NGH/KGH or Medication Administration Record (MAR) chart, discharge letter or GP Summary and be transferred with a supply of their current medication. 5 of 11 Implementation Date: May 2016
Where possible the medical staff should ensure that a NHFT prescription chart is generated during working hours if medicines reconciliation allows. In the first instance the out of hours medical cover should be contacted if a patient arrives without a valid acute Trust drug chart from NGH/KGH and does not yet have an NHFT drug chart. If the medical cover are unable to attend the unit to generate a drug chart out of hours then nursing staff may administer the patient s own medication after reconciliation and assessment as per section 6.3 and 6.4. If an urgent prescription is required out of hours then Appendix 2 may be used by prescribers. Sensitive information should always be sent securely. For example if sent via email, the following transmissions are secure: o Sending from an nhft.nhs.uk to another nhft.nhs.uk email address o Sending from an nhs.net to another nhs.net email address. 6.3. Medicines Reconciliation by Nursing Staff When a patient is transferred between settings out of hours, reconciliation should be undertaken by two registered nurses before medicines are administered. This must also still be undertaken by a prescriber before medicines are prescribed on the NHFT drug chart. Reconciliation Follow the Medicines Reconciliation MMPO13 Medicines Reconciliation Procedure This should be undertaken using a minimum of two reliable sources of information regarding the patient s current medication. For all patients admitted from the community, where possible obtain a GP summary, including medicines and allergies, and for patient transferred from an acute hospital obtain a copy of the discharge summary and acute hospital drug chart where possible. Other sources of information include: o Patient or carer o Patient own medication (check dispensing date and labelling (query anything dispensed more than 2 months previously). o Residential/Nursing home records including the Medication Administration Record (MAR) Chart o GP repeat prescription 6 of 11 Implementation Date: May 2016
The reconciliation should be documented on the Patient s own Medicines Assessment and Administration Form (Appendix 3). 6.4. Patient s Own Drug Assessment Before using patient s own medication check that they meet the criteria for use (see MMPr014 Procedure for the Handling of Patient s Own Medication and Appendix 1). Where a patient has an individually labelled supply of medicines which have been reconciled, but an NHFT inpatient chart has not yet been written, a registered nurse may administer those medicines until a chart is generated, in accordance with the labels, providing they have established that it is safe and appropriate to do so. 6.5. Recording of Administration of Medication The prescription chart of patients transferred from one NHFT site to another do not require rewriting. However the ward details must be updated. Where patients are transferred from KGH or NGH with their original drug chart this may be used. Where patients are transferred from nursing homes, the community or without an acute Trust s drug chart from NGH or KGH, the Patient s own Medicines Assessment and Administration Form (Appendix 3) can be used to record administration. In these circumstances medication can only be administered if it is labelled for the patient and has been assessed and reconciled by two registered nurses as appropriate to use. The medication should be prescribed on an approved NHFT chart as soon as medical cover is available. The chart should be generated within 24 hours of admission or as soon as practicably possible, no later than 72 hours after admission if this is over a bank holiday weekend. A copy of the acute Trust s medication chart from NGH/KGH or Patient s own Medicines Assessment and Administration Form must be scanned onto System 1/filed as appropriate. 7. TRAINING 7.1. Mandatory Training Training required to fulfil this procedure will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Statutory and Mandatory Training Policy 7 of 11 Implementation Date: May 2016
7.2. Specific Training not covered by Mandatory Training Ad hoc training sessions based on an individual s training needs as defined within their annual appraisal or job description. 8. MONITORING COMPLIANCE WITH THIS DOCUMENT The table below outlines the Trusts monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Duties How medication is administered, including patient identification Method of monitoring Individual responsible for the monitoring Monitoring frequency Group or committee who receive the findings or report To be addressed by the monitoring activities below. Observational Modern Quarterly Medicines spot check of matron for Management medicines each clinical Committee administration area rounds Review of records of nursing staff completing medicines administration competency Modern matron for each clinical area Annually in July Medicines Management Committee Group or committee or individual responsible for completing any actions Medicines Management Committee Medicines Management Committee If there is mandatory Training will be monitored in line with the Statutory and Mandatory Training Policy. training associated with this document state the mandatory training here Where a lack of compliance is found, the identified group, committee or individual will identify required actions, allocate responsible leads, target completion dates and ensure an assurance report is represented showing how any gaps have been addressed. 9. REFERENCES AND BIBLIOGRAPHY Medicines Management Standard Operating Procedure MMSOP16 Reconciliation of Medicines and Assessment of Patient s Own Medicines Cambridge Community Services NHS Trust. 10. RELATED TRUST POLICY - MMP001 Control of Medicines Policy - MMPr008 Controlled Drugs Procedure - MMP013 Medicines Reconciliation on Admission to Hospital Policy MMPr014 Procedure for the Handling of Patient s Own Medication 8 of 11 Implementation Date: May 2016
Appendix 1: Flowchart for the assessment of PODS Is the name on the label the same as the patients? In original dispensed container? D O Label, container and medicine in good condition? Dispensed within the last 6 months? The medicine is within the expiry date on the original packaging (or on the foil/blister strip) or within the expiry date on the label of the dispensed container if there is one. If there are tablets or capsules in a bottle do they all look the same? If there are strips of tablets or capsules does the name, form and strength on the label agree with the contents of the pack? If the medicine is an ophthalmic preparation (drops or ointment), or an insulin vial/cartridge was it opened less than 4 weeks ago? Has the medicine been prescribed on the prescription chart at the same dose and frequency? MEDICINE IS SAFE FOR RE-USE If in doubt DO NOT USE and contact Pharmacy for further advice N O T U S E 9 of 11 Implementation Date: May 2016
Appendix 2: Out of Hours Request for Change in Medication A. Ward staff to complete and fax to doctor with accompanying relevant records AFTER they have consulted with the doctor on the phone. Patients full Name Date of Birth Epex/ NHS Number Name of Doctor contacted Information provided to doctor: Blood or path results Fax results with this request Patients NEWS Date & Time doctor contacted Please comment: Other presenting clinical findings Summary of Request to doctor Are you satisfied that the patient does not require a clinical visit from the doctor at the time of this request? Signature and designation/stamp of Nurse Copy of drug chart to be faxed with this request and check allergy status clear on chart B. Responding Doctor to Complete and Fax back to ward: I regret I am unable to attend the ward at this time. Please take this as a written request to amend the patient s medication. Patients Full Name Date of Birth NHS number Name of medication to start Dose and frequency Duration if applicable Additional instructions or information Name of medication to stop Additional information Signature, PRINT name, GMC number Date and time This form must be faxed to the ward and must then be scanned into system 1. Medicines will not be administered until this has been received on the ward Two Registered nurses may then transcribe the amendments to the chart and attach this form also to the chart for reference until next reviewed by a doctor. It is the responsibility of the patient s usual medical team to then review additions made at the earliest opportunity and to then countersign the transcribed medication. NB: This form cannot be used for Controlled Drugs
Medicine name, form and strength Appendix 3: Patient s Own Medicines Assessment and Reconciliation Form for the Community Hospitals Patient Name: Hospital Number: Allergies: Dose and Frequency Comments: e.g. Mixed tablets/current dose being taken different from label, patient no longer taking Date Dispensed Expiry Date Quantity Suitable for use YES/NO Sources used for reconciliation e.g. GP list, patient, discharge prescription, MAR chart, patient I have identified, assessed and reconciled the medicines Signatures of two nurse Date Medicines Administration for up to 24 hours only Date Date Date Date Time Signature Time Signature Time Signature Time Signature I have obtained consent from the patient/carer to use/dispose of the medicines as appropriate Signature of registered nurse 1: Signature of registered nurse 2: Date:... Date:...