MEDICINES RECONCILIATION POLICY Safely In, Safely Home

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1 AGENDA ITEM 1.14 Reference Number: TBA 1 Date of Next Review: TBA Previous Trust/LHB Reference Number: not applicable Policy Statement MEDICINES RECONCILIATION POLICY Safely In, Safely Home Cardiff and Vale University Health Board (CAVUHB) are committed to ensuring that patients have their medications reconciled as soon as possible on admission and that responsibility for medicines reconciliation is a multidisciplinary approach.. Policy Commitment The aim of this policy is to ensure that when a patient is transferred from one healthcare setting to another, a full accurate and current list of medications is created in a timely manner from reliable sources with clear documentation of any changes, discrepancies or omissions. Supporting Procedures and Written Control Documents 1. Medicines reconciliation: a guide to implementation. National Prescribing Centre. 2008, available at: ation_guide.pdf (Accessed February 2014) Other supporting documents are: Technical patient safety solutions for medicines reconciliation on admission of adults to Scope hospital. National Institute for Health and Clinical Excellence & National Patient Safety Agency. December 2007, available at: (Accessed February 2014) This policy relates to all unscheduled and elective admissions to CAVUHB.

2 Medicines Reconciliation Policy 2 of 11 Approval Date: dd mmm yyyy OBJECTIVES To make sure a patient gets the right drug(s), in the right dose and at the right time, continually, unless an intentional change has been made. Reduce the risk of medication errors, unintentional changes and omissions occurring when the care of a patient is passed from one care setting to another. Reduce confusion about patient s medication regimen (for healthcare professionals and for patients). Improve service efficiency and make best use of staff skills. RESPONSIBILTIES Primary care team s responsibilities on admission: To assist in the medicines reconciliation process it is requested that all patients are admitted from primary care with sufficient information about their medication and medical history. This information is referred to as the minimum data set (appendix 1). It is understood that patients presenting directly to the Emergency Unit may not bring this information with them, but it should be obtained from their relative, carer or GP s surgery at the earliest opportunity. The doctor s responsibilities on admission: On admission to hospital it is the admitting doctor s responsibility to: Take a medication history from the patient,and/or carer to the best of their ability and using the information sources available to them at that time, including the ambulance handover sheet. Document this on the medicines assessment form and include this with the admission documentation in the patient s medical notes (appendix 2). Use the medicines assessment form to document any intentional changes to regular medication made on admission and during the patient s hospital stay i.e. stopped (with reason), held (with intended review date) or amended (with reason). Annotate the medicines assessment form indicating the sources used to find the 2

3 Medicines Reconciliation Policy 3 of 11 Approval Date: dd mmm yyyy medication history, the name, signature and bleep number of the admitting doctor. Write a prescription chart for the patient s hospital stay. Respond promptly (within 24 hours) to any amendments or discrepancies highlighted by the pharmacy team on the medicines assessment form; update the patient s prescription chart as necessary. It is understood that the quality and accuracy of the initial medication history may be limited, particularly outside of normal working hours, owing to lack of access to key information sources e.g. GP records. Every effort should be made to obtain this information e.g. using the patient s individual health record (IHR). Any inaccuracies and incomplete information must be rectified as soon as possible. For potential sources of information see appendix 3. The pharmacy team s responsibilities on admission: On admission to hospital it is the pharmacy team s responsibility to: Check the medication history documented on the medicines assessment form by the doctor using at least one reliable source (preferably two). This can include sources previously accessed by the doctor. Reconcile the patient s medications by comparing the medication prescribed on the drug chart to the medication history, ensuring that any omissions or changes are intentional by referring to the medicines assessment form (Appendix 2). If changes and omissions have been made without reference to them on the medicines assessment form then an explanation and rationale will be requested from the doctor in charge of the patient s care and documented on the medicines assessment form for future reference. Any medication found to be required but not documented in the medication history obtained by the doctor will be documented on the medicines assessment form so that it is accurate and complete. These discrepancies will be communicated to the doctors in an appropriate and timely manner for their attention and appropriate action. Document which doctor the information has been relayed to and their bleep number. The pharmacist will sign and annotate the form with their name and contact/bleep number against the entries they have made. 3

4 Medicines Reconciliation Policy 4 of 11 Approval Date: dd mmm yyyy When the medicines assessment form is accurate and complete and prescribers have made any changes as appropriate to the drug chart then a full medicines reconciliation has been completed. This should normally be carried out within 24 hours of admission except at weekends when there may be a delay of up to 72 hours. This would normally fit with likely access to GP records. On confirming the drug history, the drug history section on the front of the drug chart must be signed and dated documenting the sources used. When all medications have been successfully reconciled, the medicines reconciliation section on the front of the drug chart must be signed and dated by the pharmacist. Any further changes to medication during a patient s hospital stay must be documented in the medical notes with a clear explanation of the reasons for change. If a pharmacy technician finds any discrepancies when completing a POMS check then these should be highlighted to the pharmacist for action. Where appropriate, discrepancies and action to be taken should be communicated to the nurse looking after the patient. The nurses responsibilities: Ensure all medicines supplied for a patient are held securely, are accessible, and are transferred with the patient. Medicines brought into hospital are the patient s personal property and should be dealt with accordingly. Medicines reconciliation issues may be picked up whilst administering the patient s medication. Any discrepancies should be discussed with the doctor and/or pharmacist. Any outstanding issues on the medicines assessment form should be prompted for review. As part of the discharge process nursing staff should go through the discharge medication with the patient and/ or carer to make sure they are aware of any changes made during admission. 4

5 Medicines Reconciliation Policy 5 of 11 Approval Date: dd mmm yyyy Any concerns or questions raised by the patient/carer must be confirmed by reference to the medicines assessment form or referred to the doctor. On Discharge: When the patient is discharged it is important to communicate information about medication changes to the patient s GP. This should be done on both the discharge prescription ( To Take Home or TTH form, e-discharge letter or MTeD communication) and the discharge summary by the doctor. This is because there is sometimes a delay in the discharge summary being written or reaching the GP s practice and the TTH form generally reaches the practice sooner. It is the doctor s responsibility to complete the discharge summary and document any medication changes in the relevant section from the information in the medical notes and/or medicines assessment form. Equality Impact Assessment Health Impact Assessment Policy Approved by Group with authority to approve procedures written to explain how this policy will be implemented Accountable Executive or Clinical Board Director An Equality Impact Assessment (EqIA) has been completed and this found there to be a mixture of positive and negative impact. However, any potential negative no impact can be mitigated against through working closely with carers, family members and advocates and through patient-centred care and training.. A Health Impact Assessment is not required for this policy. Quality, Safety & Experience Committee Corporate Medicines Management Group Nursing and Midwifery Board Executive Medical Director 5

6 Medicines Reconciliation Policy 6 of 11 Approval Date: dd mmm yyyy Disclaimer If the review date of this document has passed please ensure that the version you are using is the most up to date either by contacting the document author or the Governance Directorate. Summary of reviews/amendments Version Number Date Review Approved Date Published Summary of Amendments 1 2 6

7 Medicines Reconciliation Policy 7 of 11 Approval Date: dd mmm yyyy Appendix 1 Minimum data set to assist effective medicines reconciliation on admission (admissions from primary to secondary care) Date of admission Patient s name Date of birth Address Registered GP, surgery address and phone number Allergies Adverse drug reactions Presenting condition plus co-morbidities Full list of current medications (including those bought over the counter where known and medication supplied by other sources e.g. secondary care) to include: o Dose o Frequency o Formulation o Route o Date prescription last issued o Usual quantities on prescription An indication of any medicines that are not intended to be continued 7

8 Medicines Reconciliation Policy 8 of 11 Approval Date: dd mmm yyyy Appendix 2 Example medicines assessment form Appendix 3 8

9 Medicines Reconciliation Policy 9 of 11 Approval Date: dd mmm yyyy Sources of information for medicines reconciliation Always check documents for the patient s name, date of birth, address and date. The sources below will each have their own limitations and it is important to recognise the risks associated with each source. Using more than one source of information is the preferred option. 1. A recent print out from a GP computer system This is a very useful source of information. This should be verified with the patient where possible to ensure they are still taking all the medications listed and to check for use of any over the counter, herbal or nonprescribed medications/ remedies. Take note of the amount of medication issued as giving 7 days may indicate use of a blister pack. Patients may take their medication differently to how it is prescribed or have been given a verbal instruction to change a dose. N.B. there is a risk that medications not prescribed by the GP may not be included in their clinical record system. Also check date the item was last issued. 2. Individual Health Record (IHR) Obtain consent form the patient before accessing their IHR and ensure that the information is the most up-to-date. This may not be available for all GP surgeries. 3. Repeat prescription slips The date of printing should be checked and the list verified by the patient or carer where possible. N.B. seasonal products and one-off prescription items (acute) may not appear on the list of current medications. 4. Patient s own drugs (PODs) Patients may bring in their own medications, check the name and date of dispensing on the label alongside the dosage instructions. This selection may not be complete so check for those left at home. If there are no PODs with the patient check if they use a blister pack. Check with patients 9

10 Medicines Reconciliation Policy 10 of 11 Approval Date: dd mmm yyyy who have their medication supplied in a blister pack/ monitored dosage system by a community pharmacy which one they use and if they have any other medications that aren t supplied in the pack e.g. inhalers, eye drops, topical items, some tablets/ capsules, liquids etc. 5. Community Pharmacy If the patient only ever attends one community pharmacy for their medication a current drug history can be checked with dispensing records. 6. Recent discharge prescriptions If the patient has been a recent inpatient and possibly had their regular medications amended without the GP yet altering their records. If the date of discharge is more than 4 weeks ago then also check with GP in case of any changes since discharge. This is only accurate if medicines reconciliation was completed on that admission. 7. Nursing/ residential home medication administration records (MAR chart) Check the date on the chart to ensure the medication is current and make sure you have all pages. It is good practice to reconcile the MAR against a GP list for completeness. Pay attention to the administration section to establish if they have been taking them. 8. Patients and/ or their carers Always use terms and language that the patient will understand and be careful as pronunciation of medicine names may not always be accurate, potentially leading to confusion. The importance of bilingual healthcare for all patients in Wales is fundamental and is particularly acute in four key groups, people with mental health problems, individuals with learning disabilities, or other special needs, the elderly and young children. Research has shown that these groups cannot be treated effectively except in their first language 10

11 Medicines Reconciliation Policy 11 of 11 Approval Date: dd mmm yyyy 9. Recent hospital clinic letters to check for changes to medications or secondary care/ shared care treatment. 10. Telephone GP surgery When ringing a GP surgery for a medication history it is possible to ask for a list over the phone but a fax can be more reliable as it contains the dates of dispensing. When dealing with a fax use the safe haven faxing procedure and use a standard template for a fax request. Always confirm the patients name and address and date of birth. Check both repeat and acute prescriptions. Ask about any recorded allergies and community pharmacy details. 11