Medicines Reconciliation in Adults Policy

MEDICINES RECONCILIATION IN ADULTS POLICY

Version / 5
Name of responsible (ratifying) committee / Formulary & Medicine Committee
Date ratified / 06 December 2018
Document Manager (job title) / Director of Medicines Optimisation and Pharmacy
Date issued / 11 December 2018
Review date / 30 November 2021
Electronic location / Clinical Policies
Related Procedural Documents / Prescription Endorsing Policy
Medicines Management Policy
Controlled Drugs Management Policy
Pharmacists Enabling Protocol
Key Words (to aid with searching) / Medicines Reconciliation, Medication History Taking, Drug History Taking

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
5 / 06 Dec 2018 / Updates for national guidance and NICE changes, removal/simplification of overly complex sections, adjustment of 24 hours standard to align with quality contract. Appendix 4 adjusted to medication history sources only further detail to be placed in a separate drug therapy guideline / Luke Groves
4.1 / 22 Oct 2018 / Chairs action – Extension to review date / -
4 / 16 Sept 2016 / Appendix 4. Additional guidance as to safe and appropriate documentation of insulin doses. Addition of Summary Care Record as source of medication history information. Clarification of difference between medicines reconciliation requirements for ward-based and dispensary-based services. Clarification of requirements for level 1 medicines reconciliation. / Luke Groves
3 / 16 May 2014 / No change from Version 2 / Clare Becaus

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5. DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

APPENDIX 1:

Criteria for referral for Second Level Medicines Reconciliation – Pharmacy Consolidation

APPENDIX 2:

Criteria that may be used to identify patients requiring third level medication review

APPENDIX 3:

Checklist to support process of medicines reconciliation

APPENDIX 4:

SOURCES of MEDICATION HISTORIES

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

This policy must be followed in full to ensure that a high-quality and robust Medicines Reconciliation service is available for adult patients at all times.

This policy applies to all healthcare workers who are involved in the medicines reconciliation process for all adult in-patients. This includes doctors, non-medical prescribers, pharmacists and pharmacy technicians.

The policy covers the definitions and standardisations of the medicines reconciliation process for all adult in-patients.

For quick reference the guide below is a summary of actions required. This does not negate the need for all staff to be aware of and follow the detail of this policy.

All adult patients admitted to PHT should receive medicines reconciliation within24 hours of admission. This is to be conducted by a trained and competent healthcare professional – ideally a Pharmacist, Pharmacy technician, nurse or doctor with the necessary knowledge, skills and expertise.

Patients admitted to PHT who are considered a high-risk or targeted patient should receive full ‘level 3’ medicines reconciliation within 24 to 72 hours of admission. This is to be conducted by a registered pharmacist.

All staff conducting medicines reconciliation should ensure that entries are legible, signed and dated and contact details provided. Please refer to the trust endorsing policy and Medicines Management Policy for written documentation standards.

All staff conducting medicines reconciliation should follow a standardised method of information collection and documentation as specified in this policy and the endorsing policy as point 3.

To enable the monitoring of compliance to this policy a number of regular localised audits and peer reviews will be conducted.

1.INTRODUCTION

Medication errors have the potential to cause harm to hospital inpatients, and hence present a serious clinical and financial risk to healthcare organisations.

Medication errors are one of the leading causes of injury to hospital patients, and chart reviews reveal that over half of all hospital medication errors occur at the interfaces of care. The prevalence of medication discrepancies arising at transitions of care have been reported in many different settings (hospital, community and long-term care facilities) and stages of care (admission, transfer and discharge). When a patient’s transition from the hospital to home is inadequate, the repercussions can be far-reaching — hospital readmission, an adverse drug event, and even mortality

The importance and effectiveness of a robust and rigorous Medicines Reconciliation (MR) within all care settings is vital to ensuring patient safety. Medicines Reconciliation is recognised globally as a process that supports patient safety.

In addition an effective process Medicines Reconciliation significantly supports the delivery of many of the outcomes associated with the Medicines Optimisation principles as described in the NICE Guidance (March 2015) – Medicines Optimisation: the safe and effective use of medicines to enable the best possible outcomes

Medicines Reconciliation is often the first step or opportunity to understand the patient’s experience of their medicines, this can then lead to ensuring that patients take their medicines correctly, avoid taking unnecessary medicines, reduce wastage, ensure that medicines are prescribed and taken safely and improve outcomes from medicines use

In an attempt to minimise variances, all healthcare organisations which admit adult inpatients are now required to design, implement and maintain standardised systems to:

Collect accurate information on each newly admitted patient’s medication history
Create a comprehensive list of these medicines
Check this list against hospital inpatient prescription card written for the patient on admission
Ensure any discrepancies are highlighted and acted upon appropriately.

This process is termed medicines reconciliation and should ideally involve a pharmacist or medicines management technician as soon as possible after admission.

This policy outlines how Portsmouth Hospitals NHS Trust intends to implement medicines reconciliation across all inpatient services, within the constraints of existing clinical pharmacy resources, as well as to ensure that all adult inpatient services have appropriate medicines reconciliation processes in place.

2.PURPOSE

To define and standardise the medication reconciliation process for all adult in-patients.

3.SCOPE

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

ADR

Adverse Drug Reaction

Administer

To give a patient a medicinal product, dressing or medical device either by introduction into the body: orally or by injection, etc, or by external application (e.g. application of an ointment or dressing)

Clinician: a health care professional who is engaged in the direct examination, diagnosis, treatment and care of patients.

Discrepancies: 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 - discrepancies agreed by the prescriber
Unintentional – discrepancies that are not a conscious change by the prescriber

Healthcare Professional: a registered practitioner in an occupation which requires specialist education and training in practical skills in health care. The professions concerned are self-regulating and practitioners are expected to satisfy their profession’s accepted standards of practice and conduct.

For the purposes of this policy, these practitioners are accepted to include:

Registered nurses or midwives
Doctors (medical practitioners)
Dentists
Dieticians
Pharmacists
Radiographers
Registered Pharmacy Technicians
Registered Operating Department Practitioners
Podiatrists

Medicines Reconciliation (MR)

The collection and accurate identification of a patient’s current list of medicines prior to hospital admission plus the identification and recording of any discrepancies compared with the list of medicines prescribed since the hospital admission. Resolution of any discrepancies identified should occur as soon as possible using clinical judgement to ensure safe and effective patient care. (NHS England Medication Safety team)

Medication review

A structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the benefits of medicines, minimising the number of medication-related problems and reducing waste² ³.

A medication review can be accurately performed only 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.

Patient medical record

Within each setting, this is the main record in which healthcare professionals record the patient’s diagnosis, treatment and responses.

Patients Own Medicines (or Drugs): PODs: used in the context of medicines that are a patient’s own property, brought into NHS premises for treatment of that patient.

Patient Safety Federation: Aims to improve patient safety in all healthcare organisations within south central area.

Prescribe: to order in writing (or electronically) the supply of a medicinal product (within the meaning of the Medicines Act, 1968, this means a POM) for a named patient (see “Prescription”).

Prescriber: a healthcare professional that is legally authorised to prescribe a medicinal product, including medical and non-medical prescribers.

Prescription: an order for the dispensing of a medicinal product. The order is presented to a professional who is legally authorised to dispense. The order must be either:

a)in writing in a legally prescribed format and signed by the person authorised by law to prescribe

b)Made, using a Trust-agreed electronic prescribing system, by the person authorised in law to prescribe medicinal substances, and who has been provided with a secure, individual computer access password.

Prescription Record Chart

Authorised drug chart for recording inpatient prescriptions and administration. There are also “Long Stay” and Mental Health Unit versions.

Prescription chart

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

Summary Care Record (SCR)

National electronic record of medication issued by GP.

TTOs

Medicines for a patient To Take Out (usually, discharge medicines)

5. DUTIES AND RESPONSIBILITIES

The Director of Medicines Optimisation and Pharmacy is responsible for development, management and implementation of this policy at trust level. Implementation of this policy will be externally assessed by the Care Quality Commission (CQC) as part of routine inspection practice.

All staff must comply with their responsibilities with undertaking their duties involving medicines at ward and department level.

Pharmacists

Each registered pharmacist is accountable for his/her own conduct and practice in accordance with the General Pharmaceutical Council’s Standards for Pharmacy Professionals.

Pharmacists are responsible for:

Ensuring the safe, clinically appropriate and cost effective use of pharmaceutical products through involvement at all stages of medicines usage and management (including prescribing).
Providing up-to-date information and guidance to other healthcare professionals on all pharmaceutical aspects of drug therapy, pharmaceutical care and medicines management.
Conforming to legal requirements.
Advising on the individualisation of patient therapy.
Advising on patient monitoring of drug effects and side effects.
Education and counselling patients, carers and hospital staff on the safe and correct use of medicinal products.
Acting within the current PHT Pharmacists’ Enabling Protocol
Advising on drug-drug and drug-fluid interactions and compatibilities in parenterals.
Advising on the pharmaceutical requirements and proper undertaking of clinical trials.
Advising on policy and procedure writing, including the requirements for PGDs.
Advising on medicines audits.

Clinical Ward-based Pharmacy Service

The Ward-Based Pharmacy Service includes pharmacists and pharmacy technicians. A pharmacist visits all specified wards in the hospital every weekday and endeavours to see every patient and their medication charts on each visit. Where this Ward-Based Pharmacy Service is not provided or not possible due to lack of resources/ funding or staffing, this is highlighted by completing an adverse incident form or recording an entry on the risk register as appropriate.

At the weekend or on bank holidays the Pharmacy Service operates from the dispensary. Therefore at the weekend or situations where the Ward Pharmacy Service is not provided, the medication charts are sent down to the dispensary and are then screened/checked in the dispensary as part of the dispensing process.

Medicines reconciliation at level 1 will have been conducted by the admitting Doctor or non-medical prescriber in-order to write the patient’s prescription prior to a request for dispensing. When the ward-pharmacy service is not available a safety and appropriateness check can be conducted by the screening pharmacist but full medicines reconciliation (level 2 or higher) will only occur at the next ward-based opportunity or as an exception where there are specific concerns for the safety of an individual patient

Some key aims of ward-pharmacy visits are highlighted below:-

Medicines reconciliation on admission and transfer. There is a requirement under NPSA/NICE guidance to ensure that an accurate list of medicines that a patient is taking is compiled, to include OTC and alternative therapies. Any discrepancies will be identified and resolved by pharmacy staff where possible, or referred to medical staff for clarification.
The allergy status of the patient will be checked (or identified if not already done by the admitting doctor or nurse), along with the nature of any allergy. The source of this information will be documented.
The pharmacist will review each prescribed medicine to ensure that it is correctly prescribed, safe and appropriate for use in the individual patient. This review will take into account age, weight, race, allergies, renal or hepatic function and other factors where individualisation of therapy may be needed. Recommendations will be made where appropriate.
The pharmacist or technician will look at the patient’s own drugs and assess their appropriateness for continued use on the ward and at discharge.
Advice will be given about administration of medicine e.g. with regard to mealtimes, compatibilities of parenteral medicines, safety requirements.
The pharmacist will screen requests for discharge medication at ward level to ensure that all necessary information is available. Medicines to take home will be dispensed at ward level or via the main pharmacy, depending on the service provided in the individual clinical area.
Pharmacy staff will advise on the safety and security of medicines in the clinical area, both at individual patient level and more generally relating to the ward or Trust policy.

Pharmacy Technicians

Each registered pharmacy technician is accountable for his/her own conduct and practice in accordance with theGeneral Pharmaceutical Council’s Standards for Pharmacy Professionals.

Pharmacy technicians are responsible for:

Education and counselling patients, carers and hospital staff on the safe and correct use of medicinal products.
Conforming to legal requirements.
Checking the suitability of PODs for reuse within the trust and on discharge.
Participating in the clinical ward based pharmacy service as specified above.

Prescribers

Each prescriber is responsible for prescribing and administering medications correctly in accordance with this policy.

When a prescriber is not confident of his/her own competence to prescribe or administer a particular medicinal product, he/she should not continue until he/she has sufficient working knowledge of it

Prescribers are responsible for:

Adhering to the Portsmouth and South East Hampshire Prescribing Formulary
Ensuring the safe and clinically appropriate use of medicines
Using up-to-date information and guidance on all pharmaceutical aspects of drug therapy
Discussing the aims and side effects of drug treatment with the patient or their representative, if possible.
Conforming to legal requirements
Individualising patient therapy
Documenting patients’ allergy status in patient notes and on patients’ drug chart including type of reaction and source of information.
Documenting the treatment plan, including how the response to drug therapy is to be monitored, clearly in the patient’s clinical notes.
Checking the patient’s medical record and allergy status before a new prescription is written
For discharge prescriptions from the Acute Medical Unit only new and amended medicines should be prescribed. This should be made clear to the GP in the narrative on the discharge summary letter.

New medicines or service developments involving the use of medicinal products, and other changes to the Portsmouth and South East Hampshire Formulary should be managed through the PHT Formulary and Medicines Group (FMG), using the resources on the managed introduction of new medicines guidelines available on the Formulary and Medicines Group homepage.

6.PROCESS

6.1 Levels of Medicines Reconciliation

6.1.1 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 and the level of pharmacy service being offered (ward-based clinical service vs dispensary service) 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.

6.1.2 Summary of levels of medicines reconciliation

Level / Brief description / Patient groups / Referral criteria
to next level
First / Admission or transfer-led
“Drug History” / All / Appendix 1 & 2
Second / Pharmacy consolidation / Defined / Appendix 2
Third / Medication review
“Clinical screen” / High risk/targeted patients / Not applicable

6.1.3 Practical definitions