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 Medicines Reconciliation / 16
Appendix 2:Checklist to support process of medicines reconciliation
Appendix 3: Collecting information for medicines
reconciliation / 18
19
Appendix 4: Collecting information for medicines reconciliation / 23
Working group members / 26

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
  • The next steps for the group include:
  • Incorporating comments from the Clinical Pharmacy Network
  • Further clarification of levels of medicines reconciliation
  • Identifying criteria that can be used to support defining standards
  • 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 .

Mira Jivraj

Emergency Services Pharmacist, NorthwickParkHospital

Linda Dodds and Jane Nicholls

East and South East England Specialist Pharmacy Services

1DEFINITIONS

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 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 settingthat have been changed intentionally and agreed with theclinician(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.

1.4Patient medical record

Within each setting, this is the main record in which the clinicians record the patients’ diagnosis, treatment and responses.

1.5Prescription chart

This refers to the chart used to record the prescribing and administration of medicines during the inpatient stay.

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.

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. .

2.2Summary of levels of medicines reconciliation

Level / Brief description / Patient groups / Referral criteria
to next level
First / Admission or transfer-led / All / Appendix 1
Second / Pharmacy consolidation / Defined (Section 5) / Appendix 1
Third / Medication review / High risk/targeted patients / Not applicable

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

(a)First Level - Admission-led

Patient group / By whom / Collection Method / Sources / Time frame
ALL adult admissions / - Admitting doctor
- Other healthcare professional (who has received appropriate training)* / Using checklist as a reminder (Appendix 2),supported by appropriate training* / 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 / By whom / Collection Method / Sources / Time frame
Agreed adult admissions, utilising guidelines in Appendix 1 to aid prioritisation / -Pharmacists
- Accredited members of the pharmacy team(may include technicians andpre-registration pharmacists)* / Using checklist as a reminder (Appendix 2),supported by appropriate training. / 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

(c)Third Level - High-risk/Targeted patients requiring a pharmacist review

Patient group: Identified high-risk/targeted patients (Appendix 1). These will include patients referred to a nominatedpharmacist 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.

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 2reliable 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). Thisis 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

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

4.0 TRAINING AND ACCREDITATION*