Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
East and South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Directorate of Clinical Pharmacy A template policy for medicines reconciliation CONTENTS PAGE NUMBER Explanatory Notes 2 1.0 Definitions 4 2.0 Levels of medicines reconciliation 7 3.0 Process 10 4.0 Training and Accreditation 12 5.0 Standards 13 6.0 Future aspirations 15 Appendix 1: Criteria for referral for Second and Third Level 16 Medicines Reconciliation Appendix 2: Checklist to support process of medicines 18 reconciliation Appendix 3: Collecting information for medicines 19 reconciliation Appendix 4: Collecting information for medicines reconciliation 23 Working group members 26 East and SE England Specialist Pharmacy Services February 2009 1 Vs11 Explanatory Notes This policy has been worked up by a small group of volunteers from the Clinical Pharmacy Network. We are very grateful for their hard work and for their own local policies which they shared with the group and which have been incorporated into this template. Our aim is that this template will act as a ‘gold standard’ for setting out how effective pharmacy-led medicines reconciliation (MR) must be delivered if the beneficial patient outcomes are to be achieved; however, we also recognise it is a work in progress and we shall strive to improve it further with your feedback It is also recognized that all medicines reconciliation should be verified by pharmacy; however, this may not always be possible due to limited pharmacy opening hours and/or limited availability of appropriately trained staff. This policy has therefore been designed to acknowledge this and ensure that services are prioritized to those patients with greater need. The group recognises that trusts across the geography will have very different starting points for delivering MR, with some trusts currently carrying out only a few MRs on selected wards, whilst others manage 80-90% coverage of all admitted patients. This policy should help each trust to set out a policy that defines the local service, but also sets an aspirational policy which can be used to work up a business case for more staff, or to underpin service redesign in order to redirect staff time to this priority activity The document is intended to be used to support trusts to deliver a policy on MR for all adult admissions by December 12th 2008. It thus contains just the elements we consider appropriate for inclusion in a trust-wide policy. Some trusts may feel it is appropriate to add further information, such as the benefits of medicines reconciliation Each trust should consider the document recommendations in the context of their own local policies and working practices. When it is felt local consideration of issues are particularly important this has been stated in italics Medicines reconciliation as set out in the NPSA document is essentially a technical process. As pharmacists we are aware that there is an important clinical aspect to reconciliation. This has been incorporated into the policy through the defining of levels of MR; however, we acknowledge that much work still needs to be done to clarify this concept and the working group will continue to meet (see Section 6) If you have any policies or material which might support the writing of the referral pathways ( Appendix 1) or to add to the Checklists, we would be grateful if you would share them East and SE England Specialist Pharmacy Services February 2009 2 Vs11 The next steps for the group include: o Incorporating comments from the Clinical Pharmacy Network o Further clarification of levels of medicines reconciliation o Identifying criteria that can be used to support defining standards o Expanding and clarifying referral pathways between the various levels of medicines reconciliation The group welcomes comments on the content of this policy and its implementation. Please email any comments to [email protected]. Mira Jivraj Emergency Services Pharmacist, Northwick Park Hospital Linda Dodds and Jane Nicholls East and South East England Specialist Pharmacy Services East and SE England Specialist Pharmacy Services February 2009 3 Vs11 1 DEFINITIONS 1.1 Medicines Reconciliation Medicines reconciliation is a process designed to ensure that all medication a patient is currently taking is correctly documented on admission and at each transfer of care. It encompasses: Collection of the medication history from a variety of sources (usually a minimum of 2) Checking that medicines prescribed on admission for the patient are correct. The ‘checking’ step involves ensuring that the medicines and doses that are now prescribed for the patient accurately reflect the sources consulted. Discrepancies may be identified at this stage and these may be intentional or unintentional. Communicating any changes in medicines so that they are readily available to the next person(s) caring for the patient. Communication must include reasons for the change(s) and any follow-up requirements. Although the process and outcomes may be verbally discussed with other members of the healthcare team there must also be a written record in the patient’s medical record and/or on the prescription chart as set out in Section 3.3. Medicines reconciliation should involve pharmacists1. This means that systems to deliver medicines reconciliation in different areas of care should be supported by pharmacists and ideally involve pharmacy team members in a clearly defined process. 1.2 Medication (drug ) history taking Medication history taking encompasses: checking on allergies and sensitivities to previously prescribed medication; documenting all regular and occasional prescribed and non prescribed medications, including medicines recently started or stopped with reasons for addition or discontinuation when known; side effects to current and past medications; information on how the patient manages their medicines at home, for example if they need the support of a carer, nurse or medication reminder device. A full medication history should underpin the process of medicines reconciliation 1.3 Medication review Medication review has been defined as a structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimizing the number of medication-related problems and reducing waste² ³. A medication review can only be accurately performed once an accurate list of what the patient is currently taking, i.e. medicines reconciliation, has been completed. Medication review is a process requiring additional knowledge and skills to those required for medicines reconciliation and so the two processes have been separated East and SE England Specialist Pharmacy Services February 2009 4 Vs11 for the purposes of this document. The detailed processes involved in medication review are considered beyond the scope of this policy. 1.4 Medicines Use Review Medicines Use Review (MUR) is an advanced service within the NHS contract for Community Pharmacy. The specific aims of the service are to improve patient knowledge, concordance and use of medicines by: •establishing the patient’s actual use, understanding and experience of taking their medicines identifying, discussing and resolving poor or ineffective use of their medicines identifying side effects and drug interactions that may affect patient adherence improving the clinical and cost effectiveness of prescribed medicines and reducing medicine wastage. 1.5 Discrepancies Part of the checking process includes the identification of any discrepancies. A discrepancy can be defined as any difference between the medicines the patient had been taking in their previous care setting and the medicines prescribed in their new care setting. Discrepancies may be considered as: Intentional Unintentional Intentional discrepancies can be defined as any difference between the medicines the patient was taking prior to admission and the medicines prescribed in their new care setting that have been changed intentionally and agreed with the clinician(s) responsible for the patient's care. Unintentional discrepancies (errors, omissions or unintentional additions) can be defined as any difference between the medicines the patient was taking prior to admission and the medicines prescribed in their new care setting that is not a conscious change. 1.4 Patient medical record Within each setting, this is the main record in which the clinicians record the patients’ diagnosis, treatment and responses. 1.5 Prescription chart This refers to the chart used to record the prescribing and administration of medicines during the inpatient stay. East and SE England Specialist Pharmacy Services February 2009 5 Vs11 It is recognised that not all trusts will have a specific section in their current prescription chart to record medicines reconciliation or medicines management issues. Local decisions will therefore have to be made on how decisions and information are recorded on these two sets of documents so that they are legible and accessible to all members of the health care team. Such decisions should take into account the fact that the patient medical record is the definitive patient record. References 1. National Institute for Health and Clinical Excellence/ National Patient Safety Agency. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. Department of Health. December 2007. 2. Task force on Medicines Partnership and the National Collaborative Medicines Management Services Programme (2002). Room for Review. A guide to medication review: the agenda for patients, practitioners and managers 3. Clyne W, Blenkinsopp A, Seal R. A guide to medication review 2008. National Prescribing Centre/Medicines Partnership Programme. 2008. East and SE England Specialist Pharmacy Services February 2009 6 Vs11 2.0 LEVELS OF MEDICINES RECONCILIATION 2.1 Introduction Medicines reconciliation (MR) is the responsibility of all staff involved in the admission, prescribing, monitoring, transfer and discharge of patients requiring medicines. MR can be considered to occur at different stages or ‘levels’ which may in practice depend on the training and capability of the available staff, although ideally should be driven by the needs of the individual patient. The staff carrying out MR at any level must be appropriately trained and criteria should be clearly defined to identify when and how a patient should be referred between the different levels. Local decisions will need to be made about the level and content of training required by non-pharmacy staff in order to optimise the Level 1 medicines reconciliation process. Ideally this training should be led by pharmacy staff (Medication history taking is a competency listed under F1 training). See also Section 4. . 2.2 Summary of levels of medicines reconciliation Level Brief description Patient groups First Admission or transfer-led All Referral criteria to next level Appendix 1 Second Pharmacy consolidation Medication review Defined (Section 5) Appendix 1 High risk/targeted patients Not applicable Third 2.3 Practical definitions It is proposed that the pharmacy department will agree with clinical groups within the trust which levels of service operate in each care area. It is recognised that pharmacy staff may not be able to offer an MR service to every admitted patient within an appropriate time frame because of limited opening hours and/or limited availability of appropriately trained staff. It will therefore be necessary for any trust adapting this policy to their own requirements to prioritise Level 2 and Level 3 services to meet their local need. Those areas of care where Level 2 or Level 3 reconciliation is deemed appropriate but not possible should be added to the trust risk register East and SE England Specialist Pharmacy Services February 2009 7 Vs11 (a) First Level - Admission-led Patient By whom group ALL adult - Admitting doctor admissions - Other healthcare professional (who has received appropriate training)* Collection Method Using checklist as a reminder (Appendix 2), supported by appropriate training* Sources Time frame Preferably at least 2 (Appendix 4) Within 6 hours of admission * In areas of care where second level MR is not offered routinely, for example short stay units such as the clinical decisions unit, the process must also include referral for second level MR (pharmacy consolidation) if there are concerns about reliability or accuracy of data collected, or third level MR (pharmacist review) if the patient is locally agreed to be high-risk/targeted. Appendix 1 highlights criteria that may prompt referral for second level pharmacy consolidation or third level pharmacist review (b) Second Level – Pharmacy consolidation Patient group Agreed adult admissions, utilising guidelines in Appendix 1 to aid prioritisation By whom - Pharmacists - Accredited members of the pharmacy team (may include technicians and pre-registration pharmacists)* Collection Method Using checklist as a reminder (Appendix 2), supported by appropriate training. Sources Time frame At least 2, preferably 3 Within 48 hours of admission (or as agreed locally)** *Processes should be in place to ensure patients are referred for third level pharmacist review if complex issues are identified Although ideally all patients should receive Level 2 MR, it is acknowledged that this may not be possible in current circumstances and patients may have to be prioritised to receive this service. **The working group considered that this should ideally be within 24 hours, and no longer than 72 hours. This reflects the fact that information gathered after 72 hours may be less relevant to the patient’s care East and SE England Specialist Pharmacy Services February 2009 8 Vs11 (c) review Third Level - High-risk/Targeted patients requiring a pharmacist Patient group: Identified high-risk/targeted patients (Appendix 1). These will include patients referred to a nominated pharmacist as a result of a first level or second level medicines reconciliation By whom: Pharmacist The detailed processes involved in medication review are considered beyond the scope of this policy. The East and South East Specialist Services clinical directorate are continuing work to help define how patients might be prioritised for full medication review in different care areas. 2.4 Referral of patients for different levels of MR Where accurate medicines reconciliation has not been possible at first level, and second level MR is not routinely offered, the admitting practitioner should highlight the need for verification and refer for either a second level MR or third level pharmacist review The need for MR verification by the pharmacy team should be documented in the patient’s medical record and on the prescription chart. For criteria that may be used to prompt referral for a second level medicines reconciliation (pharmacy consolidation) or a third level medication review see Appendix 1. East and SE England Specialist Pharmacy Services February 2009 9 Vs11 3.0 PROCESS 3.1 Collection and Checking Information shall be gained from the patient and/or carer using an agreed checklist and process (e.g. Appendix 2 & 3) and ideally corroborated by at least 2 reliable sources (Appendix 4). For patients with communication difficulties caused by their acute condition, sensory or cognitive impairment or language barriers, consideration may need to be given to accessing additional sources, depending upon the individual circumstances. 3.2 Communication ‘Communicating’ is the final step in the process, where any changes that have been made to the patient’s prescription are documented and dated, ready to be communicated to the next person responsible for the medicines management care of that patient. Examples might include: When a medicine has been stopped, and for what reason When a medicine has been started, and for what reason The intended duration of treatment When a dose has been changed and for what reason When the route or formulation of the medicine has been changed, and for what reason ( this is particularly important when, for example a patient is being transferred from a high dependency unit to a medical or surgical ward) When the frequency of the dose has changed and for what reason Monitoring and follow up requirements, when these need to be actioned and by whom The patient required support to take their medicines in a previous care setting which may need to be resumed or reviewed. (a) Communication following first level medicines reconciliation (admission led). This is the responsibility of the admitting clinician Documentation should always be made in the patient medical record, noting sources used and dated and signed by the admitting practitioner Prescription chart (as list of medicines to be administered) Intentional medication changes should always be documented in the patient medical record and on the prescription chart giving reasons for the change (b) Communication following second level medicines reconciliation (pharmacy consolidation). This is the responsibility of the pharmacist or pharmacy technician who carried out the MR. Intentional medication changes not already documented should be documented in the patient medical record and on the prescription chart with reasons for the change East and SE England Specialist Pharmacy Services February 2009 10 Vs11 Decisions may be taken locally as to when this is not required, e.g. when following an agreed Integrated Care Plan that stipulates specific therapies Unintentional medication changes should be discussed with the prescriber and documented in the patient’s medical record and (if appropriate) on the prescription chart with recommendations for follow up and dated and signed by a pharmacist Monitoring and follow up requirements identified during the medicines reconciliation process should be documented in the patient medical record (and prescription chart if appropriate) and dated and signed by a pharmacist Verification of a level 1 medicines reconciliation should be noted on the prescription chart and dated and signed by the practitioner who carried out the MR If communication difficulties are encountered and the patient is NOT used as a source of information, this should be documented Local policies should clearly state which members of pharmacy staff are authorised to make entries on the prescription chart and in the patient medical record, where these entries should be made and what they include (e.g., date, time, signature, designation). Policies that enable entries to the patient medical record to be made by a pharmacy technician should state whether they must be countersigned by a registered pharmacist. It is the responsibility of the person carrying out the second level medicines reconciliation to ensure that: Unintentional discrepancies highlighted by the MR are appropriately prioritized and resolved. This may be through referral to another practitioner. Any future transfer requirements between care settings are appropriately documented in the patient medical record and where appropriate on the prescription chart with any useful telephone numbers obtained on admission, as these may aid a smooth transfer between care settings To follow local trust policies on record keeping and documentation in the patient medical record and on the prescription chart. As a minimum standard documentation in the patient medical record should include patient details, date, time, a summary of the actions as a result of the medicines reconciliation and name, signature and contact details of the individual carrying out the reconciliation. Where changes have been made to the prescription chart these should also be appropriately documented. Every effort should be made to ensure that medication changes and reasons for the changes are communicated appropriately so that the person discharging the patient can ensure the reasons for changes are communicated at the next transfer of care East and SE England Specialist Pharmacy Services February 2009 11 Vs11 4.0 TRAINING AND ACCREDITATION* Staff carrying out first level MR should receive appropriate training which is supported, delivered or led by the pharmacy department.* Face-to-face training should be delivered by pharmacists Staff carrying out second level MR will be accredited through an agreed competency assessment to carry out the service. Training may be via a locally or regionally agreed training package. Staff will be reaccredited at agreed intervals.** * Trusts will need to agree what first level training comprises and how it is delivered. Ideally it will eventually be at least partly web based, agreed as mandatory for all non-pharmacy staff who admit patients and access, and delivery monitored by a package such as training tracker. Ideally training will be transferable between trusts thus supporting a mobile workforce. ** Work is needed to clarify training and assessment requirements for pharmacy staff undertaking second level MR. Ideally this will be agreed regionally or nationally. Some work on taking this forward will be undertaken by the Clinical Directorate, East and South England Specialist Pharmacy services. East and SE England Specialist Pharmacy Services February 2009 12 Vs11 5.0 STANDARDS It is considered likely that each clinical area/care group will need to be evaluated separately within a trust, and the ratio between different levels of MR agreed based on clinical need and pharmacy resource. The following standards have been developed by the working group and may be considered as a basis for local standards and audit of the agreed service. PROCESS Adult patients will have a Level 1 MR carried out as set out in the trust standard operating procedure for MR within 6 hours of admission STANDARD: 100% Adult patients designated to require a Level 2 (pharmacy consolidation) MR will have it carried out within 24 hours STANDARD: 70% Patients fulfilling criteria for a Level 2 MR in clinical areas where Level 2 MRs are not routinely offered by pharmacy staff will be offered a Level 2 MR within an agreed time of the referral being made STANDARDS: 70% within 24 hours, 100% within 48 hours The standards for Level 2 MR reflect the current constraints in many trusts with respect to providing a service outside normal pharmacy working hours. The standards would be expected to rise as pharmacy working hours are extended. An alternative strategy would be to designate % to be completed within different time frames, e.g. 70% in 24hr; 100% in 48 hr). Ideally targets should reflect clinical need, however this may not currently be possible. Trusts should agree their standards for individual care areas taking resources and clinical need into account. DOCUMENTATION FIRST LEVEL Medications taken prior to admission should be documented in the patient medical record together with the source(s) used to obtain the information STANDARD: 100% Intentional changes to medicines are documented in the patient medical record together with reasons for the change STANDARD 100% East and SE England Specialist Pharmacy Services February 2009 13 Vs11 SECOND LEVEL Confirmation of ratification of a Level 1 MR will be documented as set out as in local policy STANDARD : 100% This recognises that some trusts do not yet have dedicated space on the prescription chart for this information Intentional medication changes will be recorded on the patient’s prescription chart as set out in the local policy document STANDARD : 100% This recognises that this information may not be added to the discharge letter if lodged only in the medical record Identified unintentional changes to the admission medication will be recorded in the patient’s medical record STANDARD: 100% Identified unintentional changes to the patient’s admission medication will be resolved before discharge STANDARD: 100% Entries on the prescription chart and in the patient’s medical record related to the MR process must be dated, signed and include a contact number for the member of pharmacy staff making the entry STANDARD 100% Intentional changes to admission medication must be documented by the doctor or nurse discharging the patient or a member of the pharmacy staff on the discharge letter STANDARD: 100% Medicines discontinued on admission will have the reason for discontinuation added to the discharge letter STANDARD 100% TRAINING Staff providing Level I and Level 2 MR will receive training and accreditation as set out in local trust policy documents STANDARD: 100% East and SE England Specialist Pharmacy Services February 2009 14 Vs11 6.0 FUTURE ASPIRATIONS Criteria for referral by ward staff to second level (pharmacy consolidation) (Appendix 1) Risk assessment and redesign of services to ensure that high risk patients are targeted and prioritized for level 3 services Introduction of an accredited training program for medicines reconciliation with reaccredidation at regular intervals Training and accreditation standards for MR to be agreed across the East and South England geography; however, in the meantime local training and accreditation may be appropriate Use of electronic learning tools to support training e.g. training tracker East and SE England Specialist Pharmacy Services February 2009 15 Vs11 APPENDIX 1a. Proposed referral criteria for Second and Third Level Medicines Reconciliation (based on work carried out at Hammersmith Hospital and by Nina Barnett, Consultant Pharmacist, Harrow PCT). These criteria should be adjusted to take into account the case mix in the ward/unit Type of Patient This list is not exhaustive and there may be circumstances where a patient does not fit any of the criteria below yet still needs a detailed MR. PRIORITY FOR 2nd level MR PRIORITY FOR3rd level MR Patients whose medication is likely to have contributed to, or caused, the current admission High High Patients with complex medical history High High Patients on drugs with a narrow therapeutic index, e.g. warfarin, digoxin, lithium, phenytoin, methotrexate High High Patients on opioids or other drugs with potential for abuse e.g methadone, benzodiazepines High High Patients who are on medication but don’t know names or doses, especially those with >4 drugs or already have a compliance aid High Medium Patients with communication difficulties (sensory or cognitive impairment, language barriers High Medium Patient with complex social1, physical2 or mental health3 issues that could suggest poor medicines management Medium Medium Straightforward drug histories e.g patients transferred from nursing homes or other care settings Medium Low Patients who have had significant or multiple intentional changes to their medication Low Low Patients with known adherence problems (or use medication reminder charts) who would benefit from assessment for compliance aids Low High Younger patients with no previous medical history Low Not required Patients recently discharged and re-admitted for non-medication related issues, e.g social Low Not required Patients due to be discharged imminently where no changes have been made to medication Low Not required 1 e.g. isolation, financial problems, low level of home support e.g. impaired sight, hearing, dexterity, mobility, swallowing, communication (language or speech) 3 e.g. cognitive impairment, mental illness, confusion, learning disabilities, disorientation 2 East and SE England Specialist Pharmacy Services February 2009 16 Vs11 APPENDIX 2. Checklist to support process of medicines reconciliation It is not intended that this checklist be completed on paper and stored for every patient, rather that it underpins training around MR and practically supports the MR process and guides the documentation that must be added to the patient medical record or the prescription chart. Patient details (full name, date of birth, weight, NHS/unit/hospital number, GP, date of admission The condition for which the patient was referred (or admitted) plus details of any comorbidities Known allergies and nature of the reaction Should be signed, dated with documentation of sources used A complete list of all of the medicines currently being taken by the patient Dose, frequency, formulation and route of all the medicines listed Specific medication to ask about include Prn medication Inhalers Eye drops Topical preparations Once weekly medication Injections OTC medication Oral contraceptives Hormone replacement therapy Nebules Home Oxygen Herbal preparations Insulin Additional information for specific drugs e.g. indication for medicines that are for short-term use only (antibiotics), day of week of administration for once weekly medication (bisphosphonates, methotrexate) Medication management in own home e.g. details of specific support from carers, dosette box, medication reminder charts Sources used (minimum of 2) Should be documented Name, signature and date of practitioner carrying out medicines reconciliation East and SE England Specialist Pharmacy Services February 2009 17 Vs11 APPENDIX 3. Collecting information for medicines reconciliation The ‘collecting’ step involves taking a medication history and collecting other relevant information about the patient’s medicines. The information may come from a range of different sources (some potentially more reliable than others). See Appendix 4. The medication history should be collected from the most recent and reliable sources. Where possible, information should be cross-checked and verified. The person recording the information should always record the date that the information was obtained and the source of the information. This section covers: A) Taking a medication history B) A checklist of questions that can support medicines reconciliation and help to identify any problems The working party would like to acknowledge the policies developed at University College Hospital, London, which underpin this appendix. In developing local policies trusts will need to take into account local methodologies for managing patients on the high risk drugs outlined. A) THE PROCESS OF MEDICINES RECONCILIATION This process may not be applicable for patients with communication difficulties. If a carer or translator is not available, consideration should be given to relying solely on a variety of external sources. In such cases, the difficulties in obtaining the drug history, the sources used and possible areas of uncertainty must be clearly documented Introduce yourself to the patient and explain the purpose of your visit. Confirm with the patient whether they have any medication allergies or Adverse Drug Reactions (ADRs). Ask also about the nature of the reaction and document this information in the patient medical record and the drug allergy/hypersensitivity box on the medication record chart: - If the patient has no known drug allergies/hypersensitivities, then document as ‘NKDA’ If the patient is unconscious/unavailable use other sources to determine allergy status where possible. This information should be signed and dated and include details of the sources used Ask the patient if they have brought their own medicines and/or a list of their medicines into hospital. Ascertain what medicines the patient was using regularly at their previous care setting prior to admission (see Appendix 4 on Sources for Drug Histories). East and SE England Specialist Pharmacy Services February 2009 18 Vs11 Ask the patient for details of medicine name, formulation, strength and frequency of administration for each medication. Where the patient has been transferred from another care setting you may need to check the medication history against the medication record chart or administration record from that setting. You may need to use your discretion and reconcile medicines from prior to admission to the previous care setting. The first source of documentation of a medication history on admission should always be the patient medical record. In addition to asking the patient about regularly prescribed medicines, also check if the patient is using any of the medicines listed in Appendix 2 as these are often forgotten by patients. Ascertain the patient’s adherence to their prescribed medication regime. Ask the patient/carer if they take/administer the medicines as labelled. Ask if they use a compliance aid. Note: Some patients are confused on admission to hospital (especially the elderly) and claim not to be taking any medicines. In such instances alternative sources may define what medicines are prescribed and a view will need to be taken on whether the patient complies or not. Specific information should be collected about the following drugs: Inhalers - It is important to confirm the name, strength and type of inhaler. Warfarin - The following points should be recorded on the drug chart for patients taking warfarin: 1. Indication, duration of treatment and target INR 2. Patient’s usual or most recent dose and time of day dose taken 3. Tablet strengths held by the patient 4. Whether patient has an anticoagulant “yellow” book 5. Date of last INR test and result (ideally record to be brought into hospital) 6. Details of clinic that they attend for their monitoring and date of next appointment Steroids - It is important to obtain an accurate history particularly for patients with asthma or COPD, IBD or arthritis. - Ask about any recent courses (within past 6 months) and if so, how many and for how long (whether they were short 5-7 day courses or reducing courses). - For those on long-term steroids this should be annotated on the drug chart so that treatment is not abruptly stopped. East and SE England Specialist Pharmacy Services February 2009 19 Vs11 Insulin - The type (human, bovine or pork), brand, administration device and dose should always be checked and annotated on the drug chart. - For those patients that say that they have an insulin pen, clarify between a pre-filled disposable pen and a penfill cartridge. Oral contraceptives /HRT - These are not always considered as medicines by the patient and should therefore be asked for. - Additional counselling may also be needed if antibiotics are started for the oral contraceptive pill Methotrexate - This is prescribed once weekly so the day of administration, strength and number of tablets taken should be confirmed with the patient. - Check that this is correct on the drug chart and that the six days of the week when the dose is not to be administered are crossed off. - Any concomitant folic acid prescriptions should also be asked about. - Ask to see the patients monitoring booklet. Bisphosphonates The day of administration should be confirmed with the patient and annotated on the drug chart. Ask the patient whether they take calcium preparations and confirm which brand. Opioids Confirm dose, brand, strength and colour of tablet Frequency of use, recent dose changes Confirm with GP if any concerns Methadone - Check whether doses have been confirmed with the Drug Treatment Centre (DTC), patient’s GP or community pharmacy - Refer to local policies (eg re urine tox screens) - Contact the community pharmacist to alert them of the patient’s admission and determine the normal dispensing schedule and when the patient last collected their methadone (daily supervised, weekly etc) - Ensure methadone is prescribed by number of milligrams not number of millilitres (since two different strengths of solution are available) - Patients do not usually get a supply of methadone on discharge. - The GP, community pharmacist and DTC contact will need to be contacted pre-discharge to agree a plan of action. Nebulisers - Identify whether the patient has own nebuliser and nebules at home and document on the drug chart. East and SE England Specialist Pharmacy Services February 2009 20 Vs11 B) A CHECKLIST OF QUESTIONS TO SUPPORT MEDICINES RECONCILIATION AND HELP IDENTIFY ANY PROBLEMS Does anyone help you with your medicines at home? If so, who? What do they do? Do you have any problems obtaining or ordering your repeat prescriptions (NB: relative / carer might help) Do you have a regular community pharmacy that you use? Do you have problems getting medicines out of their packages? Do you have problems reading the labels? Some people forget to take their medicines from time to time. Do you? What do you do to help you remember? Some people take more or less of a medicine depending on how they feel. Do you ever do this? Most medicines have side-effects. Do you have any from your medicines? Specific medication related questions such as have any medicines been stopped recently or have any doses been changed recently? East and SE England Specialist Pharmacy Services February 2009 21 Vs11 Appendix 4. Sources of Medication Histories The following sources of medication histories are listed below in no order of preference, as reliability can vary according to the situation. However it may be necessary to use two or more sources to establish an accurate medication history. The working party would like to acknowledge the policies developed at University College Hospital, London, which underpin this appendix. The Patient - This is an important source as the patient will tell you exactly how they take their medicines. - Always try to establish how exactly a patient takes their medicines, as this could be very different from the formal records. Patients Own Drugs (POD’s) - Encourage patients to bring in their medicines from home. - Discuss each medicine with the patient to establish what it is for, how long they have been taking it, and how frequently they take it. - Do not assume that the dispensing label accurately reflects patient usage. - Check the date of dispensing since some patients may bring all their medicines into hospital, including those stopped. Relatives/carers - Patients may have relatives, friends or carers who help them with their medicines. - This is common with elderly patients or with patients where English is not their first language. - Carers can be very helpful in establishing an accurate drug history and can also give an insight into how medicines are managed at home. - Be mindful of maintaining confidentiality Repeat prescriptions - Some patients keep copies of all their repeat prescriptions. Many of these may include medicines that have been stopped. - The date of issue should always be checked and each item confirmed with the patient. - If there is any doubt, the GP surgery should be contacted. GP Referral letters - These are not always reliable. - They are often written by the on-call doctor and may be illegible or incomplete. - It may be necessary to double-check the drug history with the patient, relative/carer or GP surgery. GP surgery - Ideally, a faxed list is preferable, especially if the receptionist appears to be having problems pronouncing the drug names. East and SE England Specialist Pharmacy Services February 2009 22 Vs11 - - Be aware of ‘acute medicines’, ‘repeat medicines’ and ‘past medicines’ on the receptionist’s screen. Always check when the item was last issued and the quantity issued. Specific questioning may be needed for different formulations, for example different types of inhalers (metered-dose, breath-actuated, turbohaler), different calcium preparations (Calcichew®, Calfovit D3®, Adcal D3®), or medicines which are brand specific (aminophylline, theophylline). It may be necessary for you to speak to the GP directly to clarify any discrepancies. Specifically ask whether there are any ‘Screen messages’. Some medications are ‘hospital only’ and do not appear on the usual ‘repeat list’. Compliance aids e.g. Dosette, Venalinks, Medimax. - These may be filled by the community pharmacist, district nurses, relatives or patient. - If dispensed by a community pharmacist, the device should be checked for dispensing labels which will provide the pharmacy contact details. - The date of dispensing should also be checked bearing in mind that the medicines may have changed. - Remember to check for ‘when required’ medicines and medicines that may not be suitable for compliance aids such as inhalers, eye drops, once weekly tablets etc. - Contact the community pharmacist to inform them of the patients admission to prevent unnecessary repeat dispensing. They may also inform you of the number of compliance aids that have been filled, since these may still be at the patient’s home. - The community pharmacist’s contact details should be documented on the drug chart and a discharge plan agreed. Medication reminder charts - The chart should be checked through with the patient and the date of issue noted. Recent hospital discharge summary - Check whether any changes have been made by the GP since the patient’s previous discharge from hospital. - If the patient has been home for more than two weeks it is likely that they may have visited their GP and changes made. - Discharge summaries that are more than one month old should not be used as a sole source for a drug history. Residential/Nursing home records e.g. Medication Administration Record sheets. - Useful and accurate source for a drug history. - Usually sent in with the patient. - Handwritten lists from homes should be used with care as they often have transcription errors. East and SE England Specialist Pharmacy Services February 2009 23 Vs11 In some cases it maybe necessary to investigate additional sources to obtain a complete medication history. Examples of teams that may need to be contacted for further information include: Anticoagulant clinics Community pharmacists Specialist Nurses e.g. heart failure/asthma nurse Drug and alcohol service Renal Dialysis unit Other hospitals for clinical trials/unlicensed medicines Where possible, double check with the patient/carer as to how he/she takes the medicines, as this may not be the same as on the prescription. East and SE England Specialist Pharmacy Services February 2009 24 Vs11 Clinical Pharmacy Network MR Working Group Members Mira Jivraj (Chair) Emergency Services Pharmacist Northwick Park Hospital Linda Dodds Associate Director of Clinical Pharmacy (South East Coast) East & South East England Specialist Pharmacy Services Anna Fletcher Lead Pharmacist for Admissions and A&E ( St Mary’s site) Imperial College Healthcare NHS Trust Jane Hough Pharmacy Clinical Services Manager Oxford Radcliffe Hospitals NHS Trust and Associate Director Clinical Pharmacy East and South East Specialist Pharmacy Services Parmjit Jagait Principal Pharmacist Clinical Services Ealing Hospital NHS Trust Rebecca Morgan Medicines and Emergency Services Directorate Pharmacist. UCL Hospitals NHS Foundation Trust Jane Nicholls Associate Director of Clinical Pharmacy East & South East England Specialist Pharmacy Services NHS Robin Offord Director of Clinical Pharmacy UCL Hospitals NHS Foundation Trust Kiran Phal Admissions Pharmacist Ealing Hospital NHS Trust Rebecca Willocks Principal Pharmacist Medicines Safety Barts and the London NHS Trust East and SE England Specialist Pharmacy Services February 2009 25 Vs11