NHS FORTH VALLEY Medicines Reconciliation Policy Date of First Issue 13/04/2015 Approved 09/04/2015 Current Issue Date 13/04/2015 Review Date 31/03/2017 Version 1.4 EQIA Yes 13/04/2015 Author / Contact Scott Hill Group Committee Final Approval Area Drug and Therapeutics Committee This document can, on request, be made available in alternative formats VERSION 1.4 30 th November 2016 PAGE 1 OF 18
Management of Policies Procedure control sheet Name of document to be loaded Area to be added to Medicines Reconciliation Quality Improvement Website Policy Guidance Protocol Other (specify) Type of document Immediate 2 days 7 days 30 days Priority Questions Understanding Yes No Options Where to be published External and Internal Internal only Target audience NHSFV wide Specific Area / service VERSION 1.4 30 th November 2016 PAGE 2 OF 18
Consultation and Change Record for ALL documents Contributing Authors: Consultation Process: Distribution: Scott Hill, Anne Mitchell, Lisa Conway, Ross Cheape Medicine Reconciliation multi-disciplinary working group Area Drug and Therapeutics Committee Acute Drug and Therapeutics Committee Primary Care Drug and Therapeutics Committee Quality Improvement Website Change Record Date Author Change Version Jan 2014 Ross Cheape and Lisa Conway Initial document 1.0 August 2014 Scott Hill Adaptation to initial version to encompass NHS FV wide application and to include comments 1.1 October 2014 Scott Hill Revision based on comments received from Medicines reconciliation multi-disciplinary group 1.2 March 2015 Scott Hill Revision based on comments from Acute and Primary Care DTC 1.3 APRIL 2015 Scott Hill Revision based on comments from Area DTC 1.4 VERSION 1.4 30 th November 2016 PAGE 3 OF 18
Contents Page No. 1. Introduction 5 2. Aims 6 3. Scope 6 4. Secondary Care 7 4.1 Medicines Reconciliation on admission 7 4.2 Collect and confirm information 7 4.3 Communicate 8 4.4 Prescribe 9 5. Medicines Reconciliation on transfer 10 6. Transcribing 10 7. Medicines Reconciliation on discharge 10 8. Roles and responsibilities 11 8.1 Medical staff/ no medical prescribers 11 8.2 Nursing 11 8.3 Pharmacy 11 9. Outpatient review 12 10. Medicines Reconciliation in Primary Care 12 11. Quality Improvement monitoring and review 12 12. References 12 13. Appendix 1 An extract from the recommended practice statement from SGHD CMO (2013) 18 1 13 14. Appendix 2 List of selected medicines that may require additional attention when creating an accurate drug history. 14 15. Appendix 3 Example Medicines Reconciliation form. 15 16. Appendix 4 -Medicines Reconciliation on Discharge into primary care. 17 VERSION 1.4 30 th November 2016 PAGE 4 OF 18
1. Introduction The definition of Medicines Reconciliation is: The process that the healthcare team undertakes to ensure that the list of medication, both prescribed and over the counter, that I am taking is exactly the same as the list that I or my carers, GP, Community Pharmacist and Hospital Team have. This is achieved in partnership with me through obtaining an up-to-date and accurate medication list that has been compared with the most recently available information and has documented any discrepancies, changes, deletions or additions resulting in a complete list of medicines accurately communicated. Scottish Government (2013) Accurate and timely Medicines reconciliation on admission to, and discharge from, hospital is an integral part of clinical care and patient safety and takes time to complete. Scottish Government (2013) Medication errors are one of the leading causes of avoidable harm suffered by hospital inpatients. These can lead to increased morbidity and mortality, a prolonged length of stay in hospital and ultimately an increase in the economic burden. There are a number of key transition points where medication errors can occur including admission, discharge and transfer of patients from one specialty to another. Errors may occur during the admission and discharge process when: -Determining the medication the patient is currently taking, from written records or the accounts of the patient, relatives or carers. - Transcribing details of the patient s medication to the hospital record - Prescribing medication for the patient after admission - Incomplete transcription on GP record on discharge from hospital. VERSION 1.4 30 th November 2016 PAGE 5 OF 18
Medicines Reconciliation is a key component of the Scottish Patient Safety Programme (SPSP) whose overall aim is to reduce mortality by 20% and reduce adverse events by 30%. The target set by SPSP for Medicines Reconciliation is that 95% of all patients admitted to the acute hospitals will have their medicines accurately reconciled with 24 hours of admission. NHS Forth Valley has developed this policy to reduce clinical risk and improve patient safety ultimately improving the quality of the service delivered to patients. This process is vital to patient safety to ensure that important medicines are not unintentionally discontinued during a hospital admission and that new medicines are prescribed with a complete knowledge of the patient s current medicines, including non-prescription medicines and allergy status. Medicines Reconciliation is recognised as a system wide process and is not limited to secondary care. Primary care services should include processes to ensure that the list of medicines that the patient takes is exactly the same as the patient is taking when the patient returns into primary care from another healthcare setting. This ensures that all intentional changes are continued with the full agreement of the primary care prescriber. It is the responsibility of NHS Forth Valley to be able to demonstrate compliance in discharging their clinical governance responsibility around medicines reconciliation by ensuring implementation and monitoring of contemporaneous Scottish Government Guidance. 2. Aims To ensure that safe and accurate prescriptions are generated on admission to and discharge from hospital embedding this with other strategic policies. To standardise the process of Medicines Reconciliation across NHS Forth Valley, reducing the risk of harm and waste. To ensure that the right patient gets the right medicines at the right time, every time. Identify the roles and responsibilities of each member of the healthcare team in ensuring accurate Medicines Reconciliation. Reduce the risk of harm to patients by ensuring a seamless transition of care. 3. Scope This policy will promote a person-centred approach to medicines management by all members of the healthcare team. This policy will apply across all hospitals, clinics, treatment teams and healthcare settings in both primary and secondary care within VERSION 1.4 30 th November 2016 PAGE 6 OF 18
the NHS Forth Valley Health Board area and specific segments from the policy will apply to different areas of care. This policy applies to all health professionals involved in the process of Medicines Reconciliation at the key transition points of admission (including pre-assessment), transfer across hospital units, discharge and the movement of the patient back into primary care. The Medicines Reconciliation process should aim to be undertaken within 24hours of admission for all patients accessing acute healthcare services within NHS Forth Valley and at the point of transfer and discharge. In Primary care the Medicines Reconciliation process should take place with in 7 days of the Immediate Discharge Letter (IDL) being received by the practice. 4. Secondary Care 4.1 Medicines Reconciliation on Admission This process will be undertaken by the admitting clinical team (doctor or nurse prescriber where appropriate) to any healthcare setting as early as possible in the admissions process. It is the responsibility of the consultant on the first ward round to ensure that medicines reconciliation has been completed. (Alternatively the ward can nominate another clinical team member who will be responsible for ensuring medicines reconciliation is completed.) In Mental Health areas where the admitting doctor (or nurse prescriber) cannot undertake this process it becomes the responsibility of the nurse receiving the patient on the admission ward. This should be clearly communicated to the nurse receiving the patient on the admission ward to ensure that this is completed. 4.2 Collect and Confirm Information The information to be collected on admission to secondary care is described in SGHD CMO (2013) 18 1. Medicines Reconciliation on admission should be a standardised process to record all medicines that a patient is taking at home, including prescription and non-prescription medicines. The Medicines Reconciliation process is integral to the prescribing process, and will reduce the need for transcription and repetition of work. An extract from the recommended practice statement is attached as Appendix 1. The Medicines Reconciliation process is initially undertaken by the admitting clinical team and the complete process should be finalised within 24 hours of a patient s hospital admission. Pharmacy team input takes place as soon as possible during patient admission. The date of the source information being used should be checked to ensure the medicine information gathered is current. VERSION 1.4 30 th November 2016 PAGE 7 OF 18
Whenever possible the prescribing clinician should discuss each individual medicine, dose and frequency with the patient or carer. When completing the drug history the clinical team member should consider the possibility that patients may receive medications from sources other than their GP, for example from Substance Misuse Services, Clozapine Clinics, Sexual Health Clinics, Infectious Diseases Unit, oncology clinics, renal clinics and Day Medicine. If a patient has had a recent admission then their discharge letters and referrals can be accessed via the eward system. Outpatient clinic letters can be accessed via EDMS. ECS first then ask the patient or carer One additional source as per list to clarify inadequate or conflicting information Information gathered Clinical judgement must be used to determine what sources are appropriate to obtain an accurate medicine list for each individual patient. Certain medicines may require special attention and the admitting clinical team member involved in gathering the medication history should ensure that they are aware of such medicine and that the Medicines Reconciliation process happens as soon as possible. Appendix 2 highlights some of these medicines but is not comprehensive. 4.3 Communicate The process of Medicines Reconciliation must be clearly identifiable in the patient record to demonstrate that careful consideration has been given to each prescription. The Medicines Reconciliation form should be completed within 24hours of admission with the following information. An example of a Medicine Reconciliation form to be used is attached as appendix 3 and should be agreed locally. The form should ensure that all elements as per CMO letter (2013)18 1 are included. This includes: patient demographics; VERSION 1.4 30 th November 2016 PAGE 8 OF 18
allergy status on admission; drug history including generic names of medicines (unless medicines are brand specific), dose and frequency, formulations/devices if applicable, nonprescription medicines and any recently discontinued medicines Two sources of information used for the drug history, documented plan for each medicine and a record of the safe transcription of clinically appropriate medicines to the inpatient prescription chart. Forms should be utilised to collect this information until electronic solutions become available either through eward developments or through electronic prescribing. Documented Medicines Plan A plan for each medicine must be documented on the Medicines Reconciliation form (or eward system or electronic prescribing system) including the reasons for this action. This will highlight intentional discrepancies between the medicines the patient was taking prior to admission and the medicines prescribed in the new care setting Communicate any changes to the patient s medication regimen with the patient or carer. Clear documentation will also highlight unintentional discrepancies (errors, omissions or unintentional additions) between the medicines the patient was taking prior to admission and the medicines prescribed in their new care setting. The reason for a medicine being discontinued or withheld must be documented. If the decision to withhold a medicine is made a follow up review date must be planned at this stage. 4.4 Prescribe All medicines that are to be continued during the admission must be legibly written on the medication administration record in accordance with NHS Forth Valley Code of Practice 2 Section 16. 5. Medicines Reconciliation on Transfer It is acknowledged that the risk of harm increases with each transition of care. Therefore it is essential that accurate communication of prescriptions takes place between treating teams. VERSION 1.4 30 th November 2016 PAGE 9 OF 18
Medicines Reconciliation must take place when a patient moves between hospital locations, especially when moving between Acute Services and other hospital settings. Throughout an inpatient stay prescribed medicines, wherever possible, and the medication administration record should move with the patient. The medication administration record and the supply of medicines can be used as a source to check that the medicines prescribed is an accurate list of the medications the patient is receiving. 6. Transcribing Medicines Reconciliation should be undertaken whenever a patient s medicine chart needs to be rewritten. This is a particular area of risk and care should be taken to ensure accurate transcription of prescribed medicines. This ensures that medicines are reviewed and decisions regarding continuation/discontinuation are made in relation to the patient s current condition. 7. Medicines Reconciliation on Discharge When a patient is discharged from hospital Medicines Reconciliation must be performed. This will ensure the transfer of accurate medication information between the care settings. The discharge prescription must be completed using the eward System which will automatically transmit an accurate list (inclusive of frequency, route and dose) of ongoing medications to the GP with the Immediate Discharge Letter (or where unavailable through locally approved processes). This list will include any medications which have been started and stopped during the admission. For wards not operating eward the paper discharge letter will be sent to the GP practice. Medicines intentionally discontinued or amended should have a reason recorded on the discharge documentation and the indication for newly started medicines should be included. Each patient should be discharged with an accurate list of the medicines they are taking. Community pharmacy should be notified when appropriate of any changes to prescribed medicines at discharge to allow continuity of medicines supply to be arranged. Further detail on the Medicines Reconciliation process on discharge can be found in Appendix 4. 8. Roles and Responsibilities Medicines Reconciliation on admission, transfer and discharge is the responsibility of all staff involved in the admission, prescribing, monitoring, transfer and discharge VERSION 1.4 30 th November 2016 PAGE 10 OF 18
of patients requiring medicines. The consultant who first sees the patient on a ward round should ensure that Medicines Reconciliation is complete (unless the ward/department has nominated responsibility to another clinical team member) and should delegate this task if found to be incomplete. 8.1 Medical Staff/Non-Medical Prescribers Obtain and document on the Medicines Reconciliation form an accurate medication list using 2 sources. Document a plan for each medicine on the Medicine Reconciliation form Accurately transcribe clinically appropriate medicines onto the Medicine Chart Undertake Medicines Reconciliation on discharge and recording this on the eward System (or other locally approved process). 8.2 Nursing Participate in the Medicines Reconciliation process according to clinical unit procedures. Highlight to the medical staff if there are medicines that a patient normally takes at home that is not prescribed on the medicine chart. Check medicines at the point of discharge as per NHS Forth Valley Code of Practice Section 24 2 Ensure the Prescription Sheet is filed in the patient s notes after discharge. 8.3 Pharmacy Clarifying Medicines Reconciliation for all newly admitted patients. This should be completed within 24 hours of admission where possible. Exceptions to this include weekends, bank holidays, out of hours and where ward/area does not have clinical pharmacy service. Liaise with medical and nursing staff to resolve issues relating to more complex patients or where there is inadequate or conflicting information to obtain an accurate medication history. Checking that Medicines Reconciliation is undertaken accurately on transfer and discharge. VERSION 1.4 30 th November 2016 PAGE 11 OF 18
9. Outpatient Review Any medicines stopped, started or altered whilst the patient was in hospital must be communicated clearly to the patient and the GP, detailing the reasons behind these decisions. 10. Medicines Reconciliation in Primary Care Ensuring safe and reliable Medicines Reconciliation following discharge. Reliable systems should be implemented in GP practices to carry out Medicines Reconciliation after a patient is discharged. The systems developed should allow for review of the Immediate Discharge Letter and the accurate update of the patient record and repeat prescriptions. This should be an active process to ensure decisions are made on the best treatment for a patient. This process should ensure that any changes to medication are communicated to the patient or representative/carer and a check made of their understanding. 11. Quality Improvement Monitoring and review The Medicines Reconciliation Policy will be reviewed and updated every two years. The review will be conducted by the authors and will involve all previous stakeholders. Monitoring of Medicines Reconciliation will take place on a monthly basis and will be reported to Scottish Government in line with the requirements as laid out in the SGHD/CMO letter. Performance will be reported to appropriate Drug and Therapeutics committees including examples of Medicines Reconciliation omissions. Monitoring will be extended to all areas where patients can be admitted. VERSION 1.4 30 th November 2016 PAGE 12 OF 18
12. References 1. SGHD/CMO (2013)18. Safer Use of Medicines. Medicines Reconciliation: Revised Definition, Goals and Measures and Recommended Practice Statements for the Scottish Patient Safety Programme. 19 September 2013. Available from: http://www.sehd.scot.nhs.uk/cmo/cmo(2013)18.pdf. Accessed 26 March 2014 2. NHS Forth Valley Code of Practice. April 2013. Available from: NHS Forth Valley Quality Improvement. Accessed 30th May 2014 VERSION 1.4 30 th November 2016 PAGE 13 OF 18
Appendix 1. An extract from the recommended practice statement from SGHD CMO (2013) 18 1. Secondary care admission Medicines Reconciliation uses at least 2 sources. Using one source may result in only 75% information accuracy. The Medicines Reconciliation process starts with the Emergency Care Summary (ECS) then the information is verified with the patient or carer. NHS Boards should ensure staff carrying out Medicines Reconciliation have access to ECS and at least 2 other sources of information. NHS Boards are encouraged to use patients own medicines which are an excellent source for Medicines Reconciliation. Other possible sources include: o GP letter o GP practice print-out o Medicine Administration Record Sheet (MAR) o GP repeat slip o GP phone call o Community pharmacist o Nursing home phone call or kardex o Case notes/previous discharge prescription o District Nurse o Anticoagulant clinic o Hospital pharmacist records including chemotherapy o Compliance chart o Clinic letters (EDMS) o Key Information Summary (KIS) The Medicines Reconciliation document includes an indication if each medicine is to be continued, withheld or stopped with a documented reason for any variance. The Medicines Reconciliation process is completed by timely and accurate transcribing of clinically appropriate medicines onto the in-patient prescription chart. The use of electronic information e.g. ECS is used wherever possible to streamline the process and minimise potential for transcription errors. The ECS Medicines Reconciliation template is utilised. ECS is accessed using a portal rather than web browser. The integration of electronic solutions with hospital electronic prescribing and medicine administration (HEPMA) is proposed as a solution to facilitate Medicines Reconciliation on admission and discharge. Clinical break points must be included in the system to allow clinical checks. VERSION 1.4 30 th November 2016 PAGE 14 OF 18
Appendix 2. List of selected medicines that may require additional attention when creating an accurate drug history. N.B. This list is not comprehensive and only highlights certain medicines where issues can occur. Warfarin current dose should be recorded Steroids record the length of course, whether it is long term maintenance, a short course or a reducing course Chemotherapy/ Cytotoxics these are high risk medicines and need careful documentation Insulin ensure that correct dose, formulation and device are prescribed Methadone and buprenorphine the dose and when last taken must be confirmed with the GP or Addiction team and the Community Pharmacy before being prescribed. (Refer to the NHS Forth Valley Managing Substance Misuse in the In-patient setting. Available from link - NHS Forth Valley Quality Improvement) Lithium Lithium has a narrow therapeutic index. A Lithium Level should be checked on admission at 12hours post dose. Monitor for any signs of lithium toxicity. (Refer to the Guideline for the management of patients on Lithium. Available from NHS Forth Valley Quality Improvement ) Hypnotics often dose is changed frequently so always clarify dose is correct. Review at discharge and continued only if appropriate For weekly / monthly/ 3 monthly treatments including depot injections- record the dose, frequency and date of last dose administered As Required Medicines It is essential that as required medicines are clearly documented as being such and are not prescribed routinely Biological therapies ensure correct brand, dose, frequency and route of supply is noted Antiepileptics record brand/manufacturer of oral antiepileptic prescribed as it may be necessary to maintain continuity of the brand/ manufacturer Clozapine an active blood result should be confirmed and continuity of supply should be maintained VERSION 1.4 30 th November 2016 PAGE 15 OF 18
Appendix 3. Example Medicines Reconciliation form VERSION 1.4 30 th November 2016 PAGE 16 OF 18
Appendix 4. Medicines Reconciliation on Discharge into primary care. 1.1 Collect and Confirm Information Using the eward System compare the current prescription sheet (NHS Forth Valley Kardex) against the list of medicines currently held on the eward System from the point of admission. Check the case record to establish where changes in medicines have been made. Complete a list of medicines required at discharge with drug, dose, frequency and duration of treatment. 1.2 Communicate The eward system will send an Interim Discharge Letter (IDL) and list of discharge medicines to the GP 6hours after the patient is discharged. Print off a list of medicines to give to the patient. 1.3 Check The discharging Nurse must check the following: The patients medicines are being given to the right patient check name and DoB The complete prescription is being given. The correct number of doses of each medicine has been dispensed. VERSION 1.4 30 th November 2016 PAGE 17 OF 18
Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact 01786 434784. For other formats contact 01324 590886, text 07990 690605, fax 01324 590867 or e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net VERSION 1.4 30 th November 2016 PAGE 18 OF 18