South Staffordshire and Shropshire Healthcare NHS Foundation Trust Document Version Control Document Type and Title: Authorised Document Folder: Policy for Medicines Reconciliation on Admission and on Referral to Community Services Clinical Yellow New or Replacing: Replacing C/YEL/mm/07 (April 2013) Document Reference: C/YEL/mm/07 Version No. v3.0 Implementation Date: July 2011 Author: Approving body: Cathy Riley Quality Effectiveness & Risk Committee Approval Date: August 2011 Ratifying body: Trust Board Ratified Date: 25 th August 2011 Committee, Group or Individual Monitoring the Document: Medicines Management Committee Review Date: July 2013
Policy on Medicines Reconciliation on Admission NB This Policy should be read in conjunction with all Medicines Management Policies, particularly the Trust Medicines Code and Trust Formulary What is Medicines Reconciliation? It is defined by the Institute of 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: o discrepancies o changes o deletions o additions resulting in: a complete list of medications, accurately communicated. The purpose of medicines reconciliation is to: o make sure the right patient gets the right drug, in the right dose and at the right time (i.e. continuity of treatment) o reduce the risk of medication errors occurring when the care of a patient is passed from one care setting to another o provide ongoing personalised medicines management care for each patient o reduce confusion about patients medication regimens (for both healthcare professionals as well as for patients) o 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. Approaches to Medicines Reconciliation Medicines reconciliation can be considered in two discreet stages. Basic reconciliation (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 would be documented within 24 hours of admission. 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. Page 2 of 8
Policy on Medicines Reconciliation on Admission 1) The policy for medicines reconciliation on admission applies to all directorates within the Trust with in-patient facilities, and elective and emergency admissions (excludes respite care units) Stage 1 must be completed within 24 hours of admission, as part of the Care Pathway for the Management of the Physical Health and Well-being of Service Users including those with Severe Mental Illness or registered for Enhanced Care Co-ordination and inpatients in all service areas, and appropriate healthcare professionals to undertake this are usually junior (foundation) doctors (but pharmacists are also appropriate if available); suitably experienced nurse prescribers, or advanced nurse practitioners may be appropriate, as agreed and competency assessed within the clinical directorate.i 2) Stage 2 should be completed as soon as possible after Stage 1, and always within the first 2 weeks of admission. Appropriate health professionals to undertake stage 2; include those identified in stage 1 and ward nurses, i.e. to check against a secondary source and highlight any discrepancies. However, a doctor or suitably qualified nurse prescriber (working within their scope of practice) must act on the discrepancies and resolve them. 3) Pharmacists involvement is encouraged in the medicines reconciliation process in every clinical area, and where clinical pharmacy support is available, pharmacy staff are involved in medicines reconciliation as soon as possible after initiation 4) The minimum dataset of information (Appendix 1) available on admission to hospital should be obtained from the referring health service (e.g. GP practice, crisis team). When the Crisis 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. 5) Standard documentation is used to collect and document information about current medication. The key place to document completion of medicines reconciliation on admission is on the front of the Trust-wide Medicines Card, but the In-Patient Physical Health Assessment Form also contains a section on Medicines Reconciliation (Appendix 2). Documentation of medicines reconciliation on the front of the Medicines Card, for all new admissions, is subject to periodic audit (with a standard of 100% expected). 6) Sources of information about patients medicines should be up-to-date, and wherever practicable, verified. The likely reliability of the source of information should be considered, and then the priority for verification applied appropriately (for guidance, see Appendix 3). Medicines reconciliation on referral to a Trust community service Medicines reconciliation is equally important at all interfaces of care. When a patient is referred to a Trust community service, the Team should obtain information about his/her current medication from the GP at the time they are accepted as a client. Page 3 of 8
Appendix 1 Suggested minimum dataset required for admission: When patients 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: o Complete patient details i.e. full name, date of birth, weight if under 16 years, NHS/unit number, GP, date of admission o The presenting condition plus co-morbidities o A list of all the medicines currently prescribed for the patient, including those bought over-the-counter (where this is known) o Dose, frequency, formulation and route of all the medicines listed o An indication of any medicines that are not intended to be continued o Known allergies and previous drug interactions This information should be clear and legible and should be available to the hospital when the patient is admitted for planned admissions, and within 24 hours of admission for unplanned admissions. Page 4 of 8
Appendix 2- Part of: Appendix 4 : In-Patient Physical Health Assessment Form Part One Part One - To be completed by admitting Doctor/practitioner within 24 hours of admission/or next working day after admission Medicines Reconciliation Detail Documented in (tick all that apply) Prescription and administration Card Patients notes Primary Source-State Code, Date & Signed Verification Source State Code, Date & Signed Crossed checked and matched Y/N, Date & Signed Discrepancy Resolved & documented -Y/N Date & Signed Prescribed Over the counter/ Non Prescribed (If applicable) Code Detail 1 A recent print-out from a GP computer system 2 Repeat prescription tear off slips 3 Patients own drugs 4 Patients and/or their carers 5 Take home prescription summaries/hospital notes 6 Other Consider liaison with clinical pharmacist for review of complex medication regimes and polypharmacy Page 5 of 8
Appendix 3 Sources of information for medicines reconciliation: There are many potential sources of information about patients medicines although no source is reliable unless it is up-to-date. In every case, the source of information should be documented, dated and, where practicable, verified. More reliable sources: o A recent print-out from a GP computer system: although this should be verified with the patient where possible to ensure that the patient is in fact taking all of the medicines listed and that they are not taking any over-thecounter, herbal, or non-prescribed medicines or remedies otherwise acquired. N.B. there is a risk that medicines that 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 anticoagulants, unlicensed medicines, and clinical trial medication, or from other prescribers. Medicines included in shared care arrangements, e.g. methotrexate or, anti- TNFs [anti-tumour necrosis factor drugs] may not be included in a GP computer print-out. o Repeat prescription tear-off slips: the date of printing should be checked and the list verified by the patient (or carer) where possible. Remember that seasonal products (e.g. hay-fever medication) and one-off prescription items (eg antibiotics) may not appear on the list of current medicines o Patient s own drugs (PODs): often brought in by patients at the request of the hospital and in-line with locally agreed policy for the re-use of patient s own medicines. Information gathered in this way may not be complete, for example, patients may not bring oral contraceptives, topical, or inhaled preparations in with them. Patients often do not class these items as medicines. Remember also that patients may not remember to bring in fridge items or bulky medicines. o Patients and/or their carers: as patients/ carers become better informed about their condition, their knowledge of the medicines that they take will also tend to increase. However, even though patients/carers 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 o Take-home prescription summaries/hospital notes: if a patient 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 ago, then the patient s GP will need to be contacted in case any amendments have been made subsequently. (Outpatient medication records may be less comprehensive). Discharge summaries often omit medicines not initiated during the hospital admission. o The Insulin Passport is a record of the patient s current insulin products. It provides an additional check to make a patient s use of insulin safer. Where there is a discrepancy between the Insulin Passport, a patient s notes or current understanding of insulin therapy, it should be reconciled and the information in the Insulin Passport updated. o Green bags (containing a patient s own drugs): Trusts that have issued specially designed green bags to encourage patients to bring their medicines into hospital with them (e.g. Walsall Hospitals NHS Trust), have Page 6 of 8
found them invaluable in supporting the basic stage of medicines reconciliation. Less reliable sources (usually need additional verification) o MAR (Medication Administration Records) from social and care home settings. Although these are official documents, they may not have been reconciled with GP patient medication records o Community Pharmacy Patient Medication Records (PMR), repeat dispensing records and Medicines Use Review (MUR) records. Community pharmacists do not routinely have access to GP patient medication records so PMR and MUR records may be incomplete. Repeat dispensing records may not include recently prescribed acute or when required medicines o Specialist nurse care plans (including mental health) and clinical management plans specialist care plans may not contain all of the medicines that a patient is prescribed o Care home managers who may be able to provide medicines information out-of-hours o Single Assessment Process documentation (SAPs) or Care Programme Approach (CPA) documentation (may be incomplete or not up-to-date) o 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 patient 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 patient is taking: o 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 o Clinical trial/unlicensed medicines may not be labelled with the name of the medicine the issuing hospital pharmacy and/or the investigator would need to be contacted for further information. Sources that would require further investigation: o Social work teams o Drugs team/alcohol detox units o Prison service probation officers o Department of Work & Pensions o Schools o Homecare providers o Anticoagulant clinics o Walk-in centres o Family and friends o Private healthcare providers o 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. Page 7 of 8
Implementation Plan Rationale Action Lead Expecte d Date For the policy to be implemented consistently across the Trust, it needs to form part of the admission process, and link to an interrelated part of this process. The Physical Health Care Pathway was introduced to the Trust 12 months ago, as part of the admissions process, and has been audited and is being revised in light of the audit. The supporting paperwork for medicines reconciliation to be incorporated into the Physical Health Care Pathway The associated training and awareness raising will be incorporated into the roll-out of the revised care pathway Implementation of the revised care pathway (including the medicines reconciliation part) will be audited Dr Ramani Das/ Kath Chambers Dr Ramani Das/ Kath Chambers/ Cathy Riley Dr Ramani Das/ Kath Chambers/ Steve Hazeldine February 2009 February- May 2009 November 2009 Achieved Date Page 8 of 8