Download Medicines Reconciliation on Admission of Adults to Hospital

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.