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Document name: Staff group to whom it applies: Medicines Reconciliation on Admission of Adults to Hospital Guideline All clinical staff Distribution: The whole Trust Issue date: April 2009 July 2011 Dec 2015 April 2011 July 2014 Dec 2016 Next review: Approved by: Drugs and Therapeutic Committee – Dec 2015 Developed by: Kate Dewhirst, Deputy Chief Pharmacist Director Leads: Medical Director Contacts for advice or information: Kate Dewhirst, Deputy Chief Pharmacist 1. Introduction In 2005 in response to local incidents and near misses the pharmacy department of the Trust introduced medicines screening for new admissions within 24 hours or the next working day. This a key performance indicator has been developed following the 2007 NPSA and NICE joint document “Technical patient safety solutions for medicines reconciliation on admission of adults to hospital” 1 1.1 Actions required by the alert 1.1.1 All healthcare organisations that admit adult inpatients should put policies in place for medicines reconciliation on admission. This includes mental health units, and applies to elective and emergency admissions. 1.1.2 In addition to specifying standardised systems for collecting and documenting information about current medications, policies for medicines reconciliation on admission should ensure that: pharmacists are involved in medicines reconciliation as soon as possible after admission. the responsibilities of pharmacists and other staff in the medicines reconciliation process are clearly defined; these responsibilities may differ between clinical areas. strategies are incorporated to obtain information about medications for people with communication difficulties. 1.2 The Safety Problem Medication errors pose a threat of harm to hospital inpatients, leading to increased morbidity, mortality and economic burden to health services. Errors occur most commonly on transfer between care settings and particularly at the time of admission. Errors may occur at a number of stages during the admission process, including when: determining the medication the patient is currently taking, from written records or the accounts of the patient, their families or carers. transcribing details of the patient’s medication to the hospital clinical record. prescribing medication for the patient after admission. 2. Definition ‘The process of identifying the most accurate list of a patient’s current medicines – including the name, dosage, frequency and route – and comparing them to the current list you are working from, recognising any discrepancies, and documenting any changes, thus resulting in a complete list of medications, accurately communicated.’ Institute of Healthcare Improvement (IHI)3 The guidance does not include medication review but admission to hospital provides an opportunity to make appropriate changes to medication. The National Prescribing Centre defines the process of medicines reconciliation as: collecting information on medication history (prior to admission) using the most recent and accurate sources of information to create a full and current list of medicines (for example, GP repeat prescribing record supplemented by information from the patient and/or carer). checking or verifying this list against the current prescription chart in the hospital, ensuring any discrepancies are accounted for and actioned appropriately. communicating through appropriate documentation, any changes, omissions and discrepancies. Medicines reconciliation can occur when patients are admitted to hospital, transferred to other units within the hospital or to another hospital, or discharged from hospital. 3. Related documents 3.1 NPSA/2010/RRR009 Reducing harm from omitted and delayed medicines in hospital Medicine doses are often omitted or delayed in hospital for a variety of reasons. Whilst these events may not seem serious, for some critical medicines or conditions, such as patients with diabetes, angina or those with pulmonary embolisms, delays or omissions can cause serious harm or death. Patients going into hospital with chronic conditions are particularly at risk. For example, patients with Parkinson’s disease who do not receive their medicines on time may recover slowly or lose function, such as ability to walk. Timely medicines history taking and medicines reconciliation can contribute to reduction in delays and omitted medicines. 4. Policy Medication history taking and prescribing should occur as part of the full clerking process on admission to any inpatient bed. Medicines not available on the ward should be ordered as soon as possible using patient’s own medicines when appropriate. Validation and reconciliation by the pharmacy team will be carried out within 24 hours or the next working day where possible and no longer than 72 hours for onsite inpatient units and for off site units. 5. Processes and responsibilities Stage of Process Admission Medication history taking Action Required For planned admission encourage service user to bring in their own medicines and any safety booklets For emergency admission request service users own medicines and any safety booklets from relative/carers For off site units, unit to alert pharmacy to the admission On–site units, daily RiO check for admissions by pharmacy staff (Where RiO is not available eg Barnsley, pharmacy staff to check with the ward records for new admissions). Collection Use two sources if possible, see guidance in section 6 Prescribing Assess information collected and prescribe according to information acquired and current situation. Medicines Reconciliation Checking Collect/confirm information using two sources if possible, including service users own medicines. Compare with prescription chart Validate, confirm and deal with any discrepancies or medicine reviews required Responsibility Nursing and medical staff Nursing and medical staff Ward staff Pharmacy staff Nursing staff may aid in collection of information for example by requesting details from the GP Admitting medical staff are responsible for medication history taking from the service user or carer. Admitting medical staff Validated pharmacy technician/ pharmacist Validated technician band 5 and above or pharmacist Pharmacist Patient’s own medicines brought into the ward Documentation Assess for suitability of use according to Medicine Code Section 13 (checklist appendix 3) Apply “approved for use sticker” Complete agreement to use form. Any medicines not required should be destroyed in accordance with medicine code section 12 and complete destruction consent form with service user. Communication Actions taken should be recorded by all on RiO to avoid duplicate of effort and to ensure accurate records. The full medication history should be recorded as part of the medical admission record on RiO, either in the progress notes or on the dedicated form if available on RiO* Pharmacy technician Pharmacist Nursing staff (out of hours only) Pharmacy team Nursing staff Nursing or pharmacy team All Admitting medical staff Pharmacist Pharmacists should record reconciliation and any discrepancies/corrections on RiO and the ward key performance indicator form.** Any significant safety issues/incidents should be recorded on the incident management system (Datix) Provide relevant information Pharmacist or technician leaflets to service user and carer *Recommendation from review of Prescribing Observatory for Mental Health (POMH) audit is that there should be a specific form for this documentation. Until then it shall be recorded in the progress notes. ** New prescription chart will also include a section to sign to indicate to ward staff medicines have been reconciled For acute mental health onsite units the pharmacist or designated technician will identify new admissions on a daily basis. For all other wards each pharmacist will agree with the individual ward/unit a procedure for alerting the pharmacist to an admission. This will be documented in the pharmacy ward file. 6. Medication History Taking 6.1 Ideally two or more sources should be used to identify the most accurate history, one of which should involve the patient and/or their carer. 6.2 For any source used: Always confirm that you have the correct patient details (check the name and address or date of birth). Always check the source is current and any issue dates are as expected. 6.3 The following information must be documented for each medication: Drug name. Dose. Frequency. Formulation – if not plain tablets (e.g. liquids, MR for modified release, EC for enteric coated). 6.4 The medication history should also record: Allergy status and any significant adverse drug reactions. Any medicines recently stopped or started. All sources used to compile the medication history. Use professional discretion at all times 6.5 A full medication history should include the following: Allergy and or drug sensitivity status, including nature of the reaction where this is known. Regular repeat, acute and occasional medicines used. Any medicine(s) recently started, stopped or changed, and the reasons why. Any side effects experienced. Quantities of medicines the patient has at home. How much the patient usually receives on repeat prescription (patients with a history of drug overdose, for example, may only receive limited supplies). How the patient manages their medicines at home (e.g. carers, district nurses, monitored dosage systems). Does the patient take the medication as prescribed? Mental Health Act status, capacity of patient or advanced decisions. Previous Diagnosis. Previous Admissions. Are there any documented advance statements/directives? 6.6 Always be sure that the information used is up to date and relevant to the patient you are asking about – always check the patient’s name and date of birth. Provide appropriate medicine information leaflets. Sources More than one source should normally be used to collect this information: 6.6.1 The following may be used as a single source if unable to confirm with any other: Repeat prescription list or printed summary (e.g. from EMIS) o Date of last issue must be within 1 month – if in doubt contact GP surgery GP surgery o Ideally this should be faxed, especially if large number of medicines, or complicated. o Check recent issues. Medication Administration Records (MAR charts) from nursing/residential homes o Confirm hand written lists with GP surgery. o May need to double check that complete information has been provided (e.g. 1 of 2 and 2 of 2). 6.6.2 Always use two or more sources to confirm: Patient, relatives or carers o If reliable – if not then must check with other source. o NB also include: Inhalers, oral contraceptives, Hormone Replacement Therapy (HRT), once weekly medication, eye drops, ointments, ear drops, herbal medicines and over the counter medicines. o Patients own medicines o Ask relatives/carers to bring in if possible. o Confirm that the patient takes the medication as per the dispensing label. o Suitability for reuse of medicines e.g. if in current use, still intact, unexpired. GP referral letter o May be incomplete or illegible. o Double check handwritten letters with GP surgery. Reminder charts o Confirm with patient and note the date. Hospital discharge summary o GP surgery may not have up to date records if patients have been recently discharged (within 1 month). Check in old notes for copy of discharge summary o Do not assume it to be accurate unless clinically checked by pharmacist and the patient has been in hospital long enough for drug history to have been confirmed Monitored dosage systems (MDS) o Check contents of the MDS and do not rely on labels etc which may not be up to date. o Check with GP to confirm any items which are not in the MDS. Community pharmacist o Useful to confirm what has actually been dispensed and if a MDS has been issued. Community psychiatric nurse (CPN) o May be able to obtain further information about the patient’s drug history eg when a depot was last given and whether the patient regularly takes medicines. 7. Groups with additional medicines reconciliation risks Substitution opiods: o Methadone and buprenorphine (Subutex®). Doses, dispensing and supervision arrangements of methadone and other medication should be checked with the client’s key worker at the Substance Misuse Services (SMS) or equivalent prior to a dose being administered. This is in line with the Trust policy ‘Illicit substances: Practical Guidance and management’. o ‘Dose verified’ or similar must be endorsed on the chart and an entry made in the medical notes to the same effect. o Document the collection pharmacy in the medical notes (pharmacy name and phone number will suffice, although details of collection arrangements e.g. daily/weekly can prove useful at the point of discharge). o Contact the keyworker and/or community pharmacy when the patient is discharged to resume supplies in the community. Warfarin o check yellow National Patients Safety Agency (NPSA) anticoagulant record for normal dose, target range and indication o confirm with anticoagulant clinic if any doubts. o Update booklet on discharge Methotrexate o check NPSA monitoring booklet to confirm the dose. o The dose is always weekly (with the exception of some very rare chemotherapy regimes). o The dose must be verified and ‘dose verified’ or similar endorsed on the drug chart before a nurse can administer (All patients should carry a methotrexate book). o The days when the patient is not to receive methotrexate must be scored out on the administration grid of the medication chart to prevent inadvertent daily administration. o Always ensure the route of administration has been confirmed and is clearly stated. Opioid analgesics o confirm doses and formulations, taking particular care with slow release and normal release preparations. Hypnotics/benzodiazepines o check if prescribed on regular or as required (prn) basis and check length of treatment if been taking regularly. Insulin o Check NPSA booklet and patient passport. o Normal dose. o Correct type of device e.g. Flexpen®, Innolet®, Cartridge for pens. o Correct type of insulin e.g. Novomix® 30, Mixtard® 30 (not interchangeable). o Update booklet and passport on discharge. o Encourage and support self administration if appropriate. NB: Most insulin strength is 100units per ml, usually issued in 3ml cartridges or 10ml vials. This often appears as 3ml or 10ml on a GP prescription. 300units is a fatal dose. Always check the insulin dose with the patient, carer or district nurse. Lithium o Check purple lithium record booklet for dose, preparation and latest monitoring results. o Update booklet on discharge. Steroids o Duration of existing therapy i.e. start date if acute treatment or state ‘maintenance dose’ if long term treatment. Inhalers o Always document the strength e.g. ‘250’, 200micrograms. o Type of device e.g. accuhaler, autohaler, MDI and whether a spacer is used. NB: Serevent® (salmeterol – green inhaler) and Seretide® (salmeterol plus fluticasone – purple inhaler) are often confused. 8. Communication difficulties If the service user has any communication difficulties and there are any unresolved inconsistencies in medication history there are strategies detailed in the process/guidelines to supplement information. Interpreters should be employed and families and carers should be approached where appropriate. 9. Audit and Evaluation This policy will be reviewed two years after approval. Any outstanding areas will then need to be addressed by Business Delivery Units, the Pharmacy Management Board and Drug and Therapeutics Committee. NICE/NPSA audit template is available. Admission notes, medical notes and pharmacy profiles can be audited. POMH-UK co-ordinated national audits of medicines reconciliation in 2009 and 2010 the results of which have bee incorporated to the review of this document. Implementation will also require some training for medical, pharmacy and relevant nursing staff on the use of the checklist and processes. The Pharmacy Management Board will review the key performance indicator figures on a quarterly basis. 10. Documentation Admission medication history checklist Name Address DOB Ward unit/Locality Consultant Sensitivities Allergies Prescribed medication Medicines on Dose Route Frequency Patient taking as admission prescribed? Tick Comments Drug name Advanced statement/directive Reconciled by pharmacist Date / Initial Information source Tick all used Patient /carer GP surgery Meds from home Nursing home record GP print GP letter Repeat prescription Previous admission Date: Prescription from previous ward/unit Other Over the counter medicines Medicine Dose Route Frequency Herbal or alternative medicines Product Dose Route Frequency Signed Date Name Appendix 1 Admission Pharmaceutical Screening Levels Level A Prescription is reviewed in pharmacy. The chart is screened for: Legibility, legality and completeness according to the Medicine Code eg all medications are signed, allergy status, route is competed, indication, frequency and maximum dose of when required medication is completed. Interactions. Therapeutic duplications. Medication and dose are appropriate from the information available on the prescription eg age and allergy status obvious contra-indications eg NSAIDS and inhalers prescribed for asthma. Is the medication available within the Trust? There is a green result available for those prescribed clozapine (Annotate and endorse prescription as appropriate. Order non-stock medication Annotate the chart in the left hand margin with a D to alert the ward pharmacist that only a dispensary review has occurred. Or use other locally agreed means of alerting the ward. Level B Prescription is reviewed on the ward/unit/team base. As Level A, plus Accuracy of admission drug history (from service user directly, previous knowledge of service user, notes, or GP as appropriate). Comparison of this list against that prescribed ie medicines reconciliation Assessment of patient’s own medication. Level C As level B, plus Presenting complaint Past medical history Smoking, alcohol or illicit drug use identified. Immediate issues identified from these with regard to pharmaceutical treatment, eg Adverse drug reaction, contra-indication. Monitoring requested or up to date for high-risk treatments eg lithium, carbamazepine, highdose antipsychotics, olanzapine. (The focus should be on medication for mental health but physical health should also be considered.) Level D Full review including the entire above plus Past medication history On-going physical health monitoring requirements Review of entire notes Key risk areas addressed Care plan produced for future pharmaceutical care Medication discussed with service user, concordance issues identified, information provided Levels B and C will count as screening for the key performance indicator (KPI) analysis. All levels should be recorded on the KPI activity recording forms. NB Admissions to Crisis and other home treatment teams may not have prescription sheets or supplies. These reviews should still be recorded using the levels B to D but indication no chart. Eg B-A or D-A Key priorities to target Clozapine Lithium Carbamazepine High doses (above BNF recommendations) Olanzapine Combinations Adverse drug reactions Clinically significant drug interactions Four or more medications High risk medications for physical health conditions eg warfarin, methotrexate, insulin Previously identified renal or liver impairment Check for hyponatraemia for patients prescribed antidepressants, having other risk factors such as old age Secondary priorities Providing information to prescribers and care co-ordinators regarding on-going physical monitoring required for adverse reactions to psychotropics, Untreated indication Medication prescribed with no clear indication Residual symptoms requiring review of current treatments Unlicensed use documented/discussed. Physical monitoring unrelated to psychotropics These priorities are intended as a guide only. The pharmacist should at all times use their professional judgement eg if the untreated indication is angina or insulin dependant diabetes this should be a priority. Appendix 2 Pre-use assessment checklist for service users own medication. Service user name…………………………………………………….. RiO number……………………………………………………………… Date of admission……………………………………………………… For all medication brought into hospital The medicine must be clearly labelled with: The name of the service user. Name and strength of the medicine. Method and frequency of administration. Date dispensed (do not use if dispensed more than 6 months ago). Name and address of supplier. If the medicine has no dispensing label, it must not be used unless: It is a clearly identifiable in the manufacturer’s original container It is within its expiry date. In addition, for those service users admitted with medication in compliance aids The compliance aid is labelled for use by that service user The medication described on the labels matches exactly the regular medication prescribed to that service user The medication was dispensed in the last 8 weeks; this date will be determined from the dispensing labels The number of medications in the section of the compliance aid to be administered must match exactly the number specified by the labels There is no evidence that the compliance aid has been tampered with The compliance aid is a single use item; it is not one that can be opened and refilled The general appearance of the compliance aid is acceptable No medication should be used if it does not meet all of the above criteria. Assessment of medication completed by: Print………………………………………… Sign………………………………………… Date………………………………………… Appendix 3 NPSA/NICE Patient information leaflet Appendix 4 Equality Impact Assessment Tool To be completed and attached to any policy document when submitted to the Executive Management Team for consideration and approval. Yes/No 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins travellers) NO (including gypsies and YES Nationality NO Gender NO Culture NO Religion or belief NO Sexual orientation including lesbian, gay and bisexual people NO Age NO Disability - learning disabilities, physical disability, sensory impairment and mental health problems NO 2. Is there any evidence that some groups are affected differently? NO 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? YES 4. Is the impact of the policy/guidance likely to be negative? NO 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? N/A 7. Comments Maybe more difficult to reconcile people of no fixed abode previous medication regimes. Every effort will be made to accommodate this. Can we reduce the impact by taking different N/A action? If you have identified a potential discriminatory impact of this policy, please refer it to the Director of Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Director of Corporate Development or Head of Involvement and Inclusion. Appendix 5.Checklist for the Review and Approval of Procedural Document To be completed and attached to any policy document when submitted to EMT for consideration and approval. Title of document being reviewed: 1. 2. 4. 5. 6. 7. Comments Title Is the title clear and unambiguous? YES Is it clear whether the document is a guideline, policy, protocol or standard? YES Rationale Are reasons for development of the document stated? 3. Yes/No/ Unsure YES Development Process Is the method described in brief? YES Are people involved in the development identified? YES Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? YES Is there evidence of consultation with stakeholders and users? YES D&T membership, senior nurse colleagues. Content Is the objective of the document clear? YES Is the target population clear and unambiguous? YES Are the intended outcomes described? YES Are the statements clear and unambiguous? YES Evidence Base Is the type of evidence to support the document identified explicitly? YES Are key references cited? YES Are the references cited in full? YES Are supporting documents referenced? YES included Approval Does the document identify which committee/group will approve it? YES If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? N/A Via trust Intranet Dissemination and Implementation Is there an outline/plan to identify how this will be done? Yes Title of document being reviewed: Does the plan include the necessary training/support to ensure compliance? 8. 9. 10. 11. Yes/No/ Unsure Comments YES Document Control Does the document identify where it will be held? YES Have archiving arrangements for superseded documents been addressed? NA Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? NA Is there a plan to review or audit compliance with the document? YES Prescribing Observatory for Mental Health Review Date Is the review date identified? YES Is the frequency of review identified? If so is it acceptable? YES Overall Responsibility for the Document Is it clear who will be responsible implementation and review of the document? Appendix 5 YES Version Control Sheet This sheet should provide a history of previous versions of the policy and changes made Version Date Author Status Comment / changes 1 April 2009 Kate Dewhirst Produced in line with NICE/NPSA guidance 2 July 2011 Kate Dewhirst Updated in line with the Prescribing Observatory for Mental Health (POMH) audit outcome.