Document Title
Medicines Reconciliation within Dudley and Walsall Mental Health
Partnership NHS Trust
Document Description
Document Type
Policy
Service Application
Trust Wide
Version
1.0
Policy Reference no. POL 200
Lead Author(s)
This policy document was developed by members of the Medicines
Management Committee
Version
0.1
1.0
Change History – Version Control
Date
Comments
Nov 2011
Version agreed by medicines management
committee
15/02/2012
Policy agreed for ratification by Policies and
Procedures Focus Group 09/02/2012 and ratified
by Governance and Quality Committee 15/02/2012
Link with National Standards
National Heath Service Litigation Authority
Care Quality Commission
National Institute for Health and Clinical Excellence
National Patient Safety Agency
West Midlands Quality Review
Essence of Care
Aims Standards
Key Dates
Ratification Date
Review Date
Day
15
15
Month
02
02
1
Year
2012
2014
Executive Summary Sheet
Document Title: Medicines Reconciliation within Dudley and Walsall Mental
Health Partnership NHS Trust
Please tick ()
as appropriate
This is a new document within the Trust
This is a revised document within the Trust
√
What is the purpose of this document?
 To ensure that Medicines Reconciliation is conducted in a timely and
uniform way across the Trust.
What key issues does this document explore?
 The accuracy of Patients Medication on Admission.
Who is this document aimed at?
 All doctors, Registered Mental Health Nurses and Pharmacists working
for the Trust.
What other policies, guidance and directives should this document be
read in conjunction with?
 British National Formulary (BNF)
 Medicines Management Policy
How and when will this document be reviewed?
 This policy will be subject to review every 2 years. This review will be
coordinated by nominated members of the Medicines Management
Committee.
2
Document Index
1
2
3
4
5
6
7
8
9
10
11
12
13
13
Summary
Introduction
Scope
Aim
Objectives
Sources of information
Roles and Responsibilities
Processes
Communication Difficulties
Opiates
Audit
Incident Reporting
Support and Training
References
Pg No
4
4
4
4
5
5
5
6
6
6
7
7
7
7
1
2
Document Appendices
Source of medication histories
Medicines reconciliation
Pg No
8
11
3
1.
Summary
1.1
This policy sets out systems for medicines reconciliation within Dudley and
Walsall Mental Health Partnership Trust and guides staff on their roles and
responsibilities.
1.2
A Standard Operating Procedure (SOP) is available to determine the
procedure to be followed for medicines reconciliation on in-patient units.
2.
Introduction
2.1
Medication errors are one of the leading causes of injury to hospital service
users. Literature reviews highlight problems at the interface between primary
and secondary care where communication between the two services lead to
problems and errors.
2.2
The aim of the medicines reconciliation process is to ensure that medicines
prescribed on admission correspond to those that the patient was taking prior
to admission. Reconciliation should involve at least two sources.
2.3
Medicines reconciliation is defined by the National Prescribing Centre 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 (e.g. GP repeat prescribing record supplemented
by information from the patient and/or carer), and
 Checking or verifying this list against the current prescription chart in
hospital ensuring any discrepancies are accounted for and actioned
appropriately, and
 Communicating through appropriate documentation, any changes,
omissions and discrepancies
3.
Scope
3.1
Implementation of this policy will ensure that Dudley and Walsall Mental
Health Services complies with the NPSA/NICE Safety Alert ‘Technical Patient
Safety Solutions for Medicines Reconciliation on Admission of Adults to
Hospital’. It will also ensure that medicines will be reconciled when patients
are moved between Trust settings.
4.
Aim
4.1
The policy will set out how medicines reconciliation will be undertaken within
Dudley and Walsall Mental Health Services. (The SOP will set out the
procedure to be followed by the appropriate healthcare professionals)
4
5.
Objectives
5.1
The policy will:
 Support the continuity of treatment to ensure that patients get the right
medicine at the right dose at the right time
 Reduce the risk of medication errors on admission to hospital
 Provide on going personalised medicines management care for each
patient
 Reduce confusion about the patients medication regimes, for both service
users and healthcare professionals
 Improve service efficiency and make better use of staff skills and time
 Improve record keeping with respect to medication
 Reduce delays in medication supply and reduce the number of missed
doses
 Reduce the subsequent risk of medication errors and adverse drug events
6.
Sources of Information
6.1
There are many potential sources of information about a patient’s medication
although no source is reliable unless it is up to date. The last updated record
of medication may not be a complete picture of what the actual patient is
taking e.g. patient may have stopped taking the medication etc. Examples of
sources and their relative merits are in Appendix 1. Sources of information
include:
 GP surgery patient record
 Repeat prescription slip
 Hospital case notes
 Community pharmacy patient medication records
 Care home or social care medicines administration record (MAR) chart
 Patients own medication bought in from home
 Patient
 Carer
 Monitored dosage system or other compliance aid
6.2
The most recent and reliable source/s must be used for medicines
reconciliation. One source should include the patient and/or the carer and the
other should refer to professional records preferentially the G.P.
6.3
The patient should where possible be involved in the process.
7.
Roles and Responsibilities
Admitting Doctor (within 24 hours of admission)
 Obtain information on medication, including over the counter medication.
The information must be collected from the most recent and reliable source
and where possible cross checked and verified.
 List the current medication on the admission paperwork including the
source of information
5


Prescribe the appropriate medication on the in-patient medication card.
Document the initial medication management plan in the admission
paperwork, including documentation of any discrepancies or variations
from the current medication list
Admitting Nurse (within 24 hours of admission)
 Obtain information on the current medication, including Over The Counter
(OTC) medication. The information must be collected from the most recent
and reliable source
 List the current medication on the admission paperwork including the
source of information
 Any discrepancies between this list of medication and that prescribed on
admission must to be bought to the attention of the doctor as soon as
practical.
Ward Pharmacist (as soon as possible after admission i.e. next
scheduled visit to the in-patient ward)
 Verify that the medication and doses prescribed are correct using the most
appropriate source/s.
 Document on the in-patient medication card that the medication prescribed
has been checked indicating with which source/s were used and the date
of reconciliation
 Any discrepancies must be documented on the medication card and
bought to the attention of the doctor as soon as possible
8.
Process
Admission within routine working hours
Admitting team/doctor should complete the medicines record form (Appendix
2) in collaboration with nursing and pharmacy staff prior to completing the full
writing up of the prescription sheet.
Admission outside routine working hours
Prescription sheet written but reconciliation must be initiated as soon as
appropriate sources are available.
9.
Communication Difficulties
9.1
It is important to ensure that service users are involved in the reconciliation
process. Therefore if service users have communication difficulties, methods
should be used to obtain information on the medication prescribed e.g.
interpreters and carers. Information on interpretation and translation should
be sought from the Trust Equality and Diversity Lead.
10.
Opiates
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10.1
When opioid medicines are prescribed, dispensed or administered the
healthcare practitioner MUST confirm the recent dose, formulation, frequency
of administration and any other analgesic medicine prescribed.
10.2
In the case of methadone or buprenorphine for the treatment of addiction, the
patient must NOT be used to verify the medicine, formulation, dose or
frequency of administration. The prescriber (substance misuse service or GP)
or community pharmacy MUST be contacted for verification.
11.
Audit
11.1
An annual audit will be carried out to determine if reconciliation had been
carried out by a pharmacist and how long it occurred after admission. This will
be reported to the Governance department
11.2
An annual audit of missed doses will be carried out. This will be reported to
the Governance department.
12.
Incident reporting
12.1
Where it is felt that the omission could lead to patient harm, this should be
reported in line with the Trusts Incident, Near Miss and Serious incident
reporting policy.
12.2
Advice in respect to this can be sought from the Pharmacy Department and
the Clinical Governance Department.
13.
Support and Training
12.1
This policy will be disseminated to all Ward/Unit Managers who will be
responsible for ensuring their staff are familiar with the policy.
14.
References
Technical Patient Safety Solutions for Medicines Reconciliation on Admission
of Adults to Hospital. NICE and NPSA. Patient Safety Guidance 1. December
2007.
Reducing Dosing Errors with Opioid Medicines. Rapid Response Report.
NPSA. July 2008.
Medicines Reconciliation: A Guide to Implementation. National Prescribing
Centre.
7
Appendix 1
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 Patient (NB: An assessment of how appropriate it is to obtain information from
the patient at the time of admission should be made)


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 (PODs)




Encourage patients to bring in their medicines from home.
Discuss each medicine with the patient /carer 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 as patients may hoard.
Relatives/carers




Encourage relatives and carers to bring in the service users medicines from
home.
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 FP10 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.
8
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




Request a list to be faxed.
Be aware of ‘acute medicines’, ‘repeat medicines’ and ‘past medicines’ on the
receptionist’s screen.
Specifically ask whether there are any ‘Screen messages’. Some medications
are ‘hospital only’ and do not appear on the usual ‘repeat list’.
It may be necessary for you to speak to the GP directly to clarify any
discrepancies.
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, soluble 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.
Do not rely on compliance aids filled by anyone other than the community
pharmacy.
Medication Reminder Charts

The chart should be checked through with the patient and the date of issue
noted.
9
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.
Community Pharmacist

If a service user uses a regular pharmacy, the pharmacist may be able to help
with current medicines list.
Previous Care Team


May be aware of recent changes but might not hold information prescribed
elsewhere. e.g. GP
Following discharge all information may be filed elsewhere
Specialist services
In some cases it may be 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.
10
Appendix 2
MEDICINES RECONCILIATION RECORD
ALLERGIES/SENSITIVITIES/PREGNANCY
First name
GP name
Surname
Surgery
D.O.B.
NHS/Hospital No.
Ward
Consultant
Phone
Fax
Date of admission
Time of admission
Medication Name, Strength
and Form
Dose
Frequency
Information obtained from (please state)
Source 1
Completed by (name)
Pharmacy rec.check by
CHECK other medication not prescribed, e.g. Over the counter,
Internet purchase, Health food shop, Herbal, Illicit, Care home
record , other
……………………………………………………………….……………
…………………………………………………………………………….
Source 2
Source 3
Designation (admission Dr, team Dr, Nurse, other)
Date
Time
Additional information
11
Discrepancies and Comments
(tick and initial the box once
discrepancy is resolved) Record
details overleaf.
Date
Prescription
to continue on
ward/unit Y/N
MEDICINES RECONCILIATION ISSUES AND/OR DISCREPANCIES
1
2
3
Identified by…………………………..
Identified by…………………………..
Identified by…………………………..
Date
Date
Date
Resolved by
Resolved by
Resolved by
Date
4
Date
5
Date
6
Identified by…………………………..
Identified by…………………………..
Identified by…………………………..
Date
Date
Date
Resolved by
Resolved by
Resolved by
Date
Date
Date
12