Medicines Reconciliation in Adults Policy
Version
3
Name of responsible (ratifying) committee
Formulary & Medicine Committee
Date ratified
16th May 2014
Document Manager (job title)
Director of Pharmacy and Medicines Management
Date issued
28th July 2014
Review date
27th July 2016
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
3
16th May 2014
None. There have been no changes to national or local
guidance and therefore no changes required.
Policy to be transferred to new trust template and
version tracking section completed.
Clare Becaus,
Lead Technician
Medicines
Management
Title of Policy: Medicines Reconciliation in Adults Policy Issue Number 3 Issue Date 28/07/2014
(Review date: 27/07/2016(unless requirements change)
Page 1 of 25
Medicine Reconciliation In Adults Policy: Issue 3
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CONTENTS
QUICK REFERENCE GUIDE
3
1. INTRODUCTION
4
2. PURPOSE
4
3. SCOPE
4
4. DEFINITIONS
4
5. DUTIES AND RESPONSIBILITIES
6
6. PROCESS
8
7. TRAINING REQUIREMENTS
13
8. REFERENCES AND ASSOCIATED DOCUMENTATION
13
9. EQUALITY IMPACT STATEMENT
14
10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
PROCEDURAL DOCUMENTS
14
APPENDIX 1
15
Criteria for referral for Second Level Medicines Reconciliation – Pharmacy
Consolidation
APPENDIX 2
16
Criteria that may be used to identify patients requiring third level medication review
APPENDIX 3
17
Checklist to support process of medicines reconciliation
APPENDIX 4
18
Collecting information for medicines reconciliation
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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.
1.
All adult patients admitted to PHT should receive full ‘level 1’ medicines reconciliation within
6 hours of admission. This is to be conducted by the admitting doctor or other healthcare
professional who has received the appropriate training.
2. Specified adult admissions and referred first level patients admitted to PHT should receive full
‘level 2’ medicines reconciliation within 24 to 72 hours of admission. This is to be conducted
by members of the pharmacy team who have received appropriate training, as defined in this
document.
3. 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.
4. 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.
5. 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 4.
To enable the monitoring of compliance to this policy a number of regular localised audits and peer
reviews will be conducted as specified in section 9.
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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.
In their first joint patient safety guidance, the National Institute for Health and Clinical
Excellence (NICE) and the National Patient Safety Agency (NPSA), expressed concern that two
literature reviews have confirmed such medication errors most commonly occur when the
patient is transferred between care settings, particularly on admission. There can be an
unintentional variance of 30-70% between the list of medicines actually taken by the patient
before admission and those prescribed on their hospital inpatient prescription card.
In an attempt to minimise such 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
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.
‘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)
ATO
Pharmacy Assistant Technical Officers, Clinical support workers not registered with a
professional body.
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Clinician: a health care professional who is engaged in the direct examination, diagnosis,
treatment and care of patients.
CQC (Care Quality Commission): Regulates all health and social care services in England,
including those provided by the NHS, local authorities, private companies or voluntary
organisations. It also protects the interests of people detained under the mental health act.
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:
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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 selfregulating 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:
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Registered nurses or midwives
Doctors (medical practitioners)
Dentists
Dieticians
Pharmacists
Radiographers
Registered Pharmacy Technicians
Registered Operating Department Practitioners
Podiatrists
Medicines Reconciliation (MR)
A process designed to ensure that all medication a patient is currently taking is correctly
documented on admission and at each transfer of care.
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.
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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.
TTOs
Medicines for a patient To Take Out (usually, discharge medicines)
5. DUTIES AND RESPONSIBILITIES
The Director of Medicines Management 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 assessment of
compliance with outcome 9.
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 Royal Pharmaceutical Society of Great Britain’s Code of Ethics.
Pharmacists are responsible for:
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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
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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.
Some key aims of these visits are highlighted below:
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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 the Royal Pharmaceutical Society of Great Britain’s Code of Ethics.
Pharmacy technicians are responsible for:
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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.
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Prescribers
Each prescriber is responsible for prescribing and administering medications correctly in
accordance with this policy.
When a doctor 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
Doctors are responsible for:
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Adhering to the Portsmouth District 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.
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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
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New medicines or service developments involving the use of medicinal products, and other
changes to the District 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, 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
First
Admission or
transfer-led
All
Referral criteria
to next level
Appendix 1 & 2
Second
Pharmacy
consolidation
Medication review
Defined
Appendix 2
High risk/targeted
patients
Not applicable
Third
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6.1.3
Practical definitions
First Level - Admission-led
Patient group: All adult admissions.
By: Admitting doctor or other healthcare professional who has received appropriate training.
Collection Method: Using Appendix 3 as a reminder and supported by appropriate training
delivered/led by the pharmacy department.
MR to include:
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Medications taken prior to admission including dose and formulation.
Allergy/hypersensitivity history including the type of reaction
In areas of care where Second Level MR is not offered routinely, the process must also include
referral for Second Level (pharmacy consolidation) if there are concerns about reliability or
accuracy of data collected or Third Level (medication review) if the patient is agreed to be highrisk/targeted. Appendices 1 and 2 highlight criteria that may prompt referral for second level
pharmacy consolidation or third level medication review.
Sources: Preferably two, ideally three of the reliable sources listed in appendix 4
Time frame: Within 6 hours of admission.
Communication: Patient medical notes, prescription chart.
Second Level – Pharmacy consolidation
Patient group: Specified adult admissions and referred first level patients.
Although ideally all patients should receive Level 2 MR, it is acknowledged that this will not be
possible in current circumstances and patients will have to be prioritised to receive this service.
By: Accredited members of the pharmacy team this will include pharmacists and qualified
level 2 medicines management technicians.
Collection method: Agreed checklist (e.g. Appendix 3). Patient may be referred for third level
medication review if complex issues are identified.
Sources: Preferably two, ideally three of the reliable sources listed in appendix 4
Time frame: Within 24-72 hours
Communication:
 Confirmation of accuracy of first level reconciliation: annotated on prescription chart.
 Documentation of all unintentional discrepancies: prescription chart and, if appropriate, the
patient’s medical notes which must be verified, signed and dated by a registered pharmacist
or level 2 medicines management technician).
 Documentation of all intentional discrepancies: prescription chart (to ensure reason for
change recorded at next transfer of care).
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Third Level - High-risk/Targeted patients requiring a pharmacist review
Patient group: Identified high-risk/targeted patients (Appendix 2). These will include patients
referred to a nominated pharmacist 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.
6.1.4 Referral of patients for different levels of MR
 Where an accurate medicines reconciliation has not been possible at first level, and second
level MR is not routinely offered (e.g. for wards which do not have a daily pharmacist visit),
the admitting practitioner should highlight the need for verification and refer for either a
second level MR or a third level pharmacist review by contacting the lead pharmacist for their
clinical area.
 The need for MR verification by the pharmacy team should be documented in the patient’s
medical record and prescription chart by the admitting practitioner. The ward pharmacist
should be bleeped during pharmacy opening hours or contact site dispensary.
(For criteria that may be used to prompt referral for second level medicines reconciliation
(pharmacy consolidation) or a third level medication review see Appendices 1 & 2.)
6.2 Method
The process of medicines reconciliation encompasses three key steps: These steps must take
place at EACH transfer of care.
1. Collection of the medication history from a variety of sources (using a minimum of 2)
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 are correct. Discrepancies may be identified at this stage and these may be
intentional or unintentional.
3. 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 notes and/or on the prescription chart as set out in Section 6.2.3.
6.2.1
Collection (See also Appendix 4)
Information shall be gained from the patient using an agreed checklist (e.g. Appendix 3) and
ideally corroborated by at least 2 of the sources outlined in Appendix 4. If the patient is unable
to give a drug history due to communication barriers caused by their acute condition, sensory
or cognitive impairment or language barriers, consideration may need to be given to accessing
additional sources, depending on the individual circumstances.
6.2.2
Checking
The ‘checking’ step involves ensuring that the medicines, doses and formulations that are
prescribed for the patient are correct. During the checking step, discrepancies maybe identified
as intentional or unintentional. The identified discrepancies, whether intentional or
unintentional, need to be communicated to the responsible medical practitioner as described in
the section below.
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6.2.3
Communication
 ‘Communicating’ is the final step in the process. 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.
Communication following first level medicines reconciliation (admission led):
 Documentation should always be made in the patient medical record, noting sources used,
signed and dated 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
Communication following second level medicines reconciliation (pharmacy consolidation)
 Intentional medication changes not already documented should be documented in the patient
medical notes and on the prescription chart with reasons for the change.
 Unintentional medication changes should be discussed with the prescriber and documented
on the prescription chart with recommendations for follow up and dated and signed by a
pharmacist. And if appropriate in the patient’s medical notes.
 Monitoring and follow up requirements identified during the medicines reconciliation process
should be documented in the patient medical notes (and prescription chart if appropriate) and
dated and signed by a pharmacist or medicines management technician.
 Verification of a level 1 medicines reconciliation should be noted on the prescription chart and
dated and signed by the pharmacy team who carried out the MR
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 prioritised and resolved*.
 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
settings6.
 Standard documentation in the patient medical notes 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.
 To ensure that medication changes and reasons for the changes are documented on the
discharge or other transfer letter between care settings if not already added by the
discharging clinician.
*If the patient is moved between clinical areas it is the responsibility of the person carrying out
the second level MR to pass this information onto the relevant ward pharmacist in order for it to
be resolved.
6.3 Standards
6.3.1 Medicines Reconciliation
Adult patients will have a Level 1 MR carried out as set out in the trust standard operating
procedure for MR within 6 hours of admission
STANDARD: 100%
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Adult patients designated to require a Level 2 MR (pharmacy consolidation, stage 1) will have it
carried out within 24 hours
STANDARD: 70%
This standard reflects the current constraints in providing a service outside normal pharmacy
working hours. It would be expected to increase as pharmacy working hours are extended.
Patients fulfilling criteria for a Level 2 review in clinical areas where Level 2 reviews are not
routinely offered by pharmacy staff will be offered a Level 2 review within an agreed time of the
referral being made.
STANDARDS: 70% within 24 hours, 100% within 48 hours
6.3.2
Documentation
FIRST LEVEL
Medications taken prior to admission should be documented in the patient medical record
together with the sources used to obtain the information
STANDARD: 100%
Intentional changes to medicines are documented in the patient medical record together with
reasons for the change
STANDARD 100%
SECOND LEVEL
Confirmation of accuracy of Level 1 MR will be documented in the patient’s medical notes or on
the patient’s prescription chart as set out in 6.2.3.
STANDARD : 100%
Intentional medication changes will be recorded in the patient’s notes and on the patient’s
prescription chart as set out in 6.2.3
STANDARD : 100%
Unintentional changes to the admission medication will be recorded in the patient’s medical
notes an on the patient’s prescription chart.
STANDARD: 100%
Unintentional changes to the patient’s admission medication will be resolved before discharge
STANDARD: 100%
Entries on the prescription chart and in the patient’s medical notes related to the MR process
must be dated, signed and include a contact number for the member of pharmacy staff making
the entry (either bleep number or extension number).
STANDARD 100%
Intentional changes to admission medication must be documented by the doctor, or nurse
discharging the patient, or a trained member of the pharmacy staff on the discharge letter
(TTO).
STANDARD: 100%
Medicines discontinued on admission will have the reason for discontinuation added to the
discharge letter (TTO).
STANDARD 100%
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7. TRAINING REQUIREMENTS
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Clinical staff carrying out first level medicines reconciliation (MR) should receive
appropriate training, which is supported, delivered or led by the pharmacy department.
Staff carrying out second level MR will be trained and accredited by the pharmacy
department.
Training for prescribers will be led by the senior pharmacists for risk management.
Training for pharmacy staff will be led by the Chief Pharmacy Technician Medicines
Management (MM).
Technical pharmacy staff training will be undertaken by in-house and/or KSS Deanery
Medicines Management Accreditations.
Level 1 MM technicians and assistants will be trained to check through Patient’s Own
Drugs (PODs) and report any problems or discrepancies to the ward pharmacist.
Level 2 MM technicians will be trained to carry out all aspects of second level medicines
reconciliation and inform the medical staff of any discrepancies. They will be counselling
patients on any new medications.
Pre-registration pharmacists will have completed the PODs and Medicines Reconciliation
competencies as set out in their pre-registration training folder.

Re-accreditation of all MM technicians will be carried out every 2 years. If in-house trained, 2
significant events forms should be completed. If KKS Deanery trained, their current reaccreditations rules apply.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
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.
4. Medicines Reconciliation. Work Instruction. PHPSWI 17.006. Portsmouth Hospital NHS
Trust.
5. Initiation and supply of Monitored Dosage Systems. Work Instruction. PHPSWI 05.005.
Portsmouth Hospital NHS Trust.
6. Prescription Endorsing Protocols. Portsmouth Hospitals NHS Trust Pharmaceutical
Services.
7. Medicines Reconciliation. Training Package. PHPST 17.006. Portsmouth Hospital NHS
Trust.
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
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Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to
be monitored
Lead
Tool
Frequency of
Report of
Compliance
Data collection
Quarterly
Reporting arrangements
Policy audit report to:
Lead(s) for acting on
Recommendations
Monthly
Patient
Safety
Federation Audit to ensure a
patient’s allergy status is
correctly recorded.
Pharmacy Risk Team
Monthly
Patient
Safety
Federation audits to ensure
that level 1 and 2 medicines
reconciliation are carried out
with 24 hours.
Pharmacy Risk Team. It is
the responsibility of the
ward pharmacist to ensure
that the audit is carried out
on the proposed day
Data collection
An internal review of any
adverse
incident
reports
involving
medicines
reconciliation will be carried
out annually by the manager
of this policy
Director Medicines
Management & Pharmacy
Review of Datix
forms
KSS Deanery competency
assessment for medicines
management technicians via
re-accredited
qualifications
every two years
Lead Technician
Medicines Management
Biennial
assessment of
ward based work
Peer reviews through normal
pharmacy working practice
All pharmacy staff
Review of practice
Pharmacy Management
Any breaches to this policy
made by pharmacy staff will
be sent to the pharmacy
governance committee
Pharmacy Risk Team
Review of Datix
forms
Pharmacy Management
Any breaches to this policy
made by other healthcare
professionals will be sent to
their clinical service centre
management
CSC Risk Advisor
Review of Datix
forms
CSC Management

Medicine Reconciliation In Adults Policy: Issue 3
Quarterly
Policy audit report to:

Quarterly
Biennial
Review date: May 2016
Quality contract
Quality contract
Policy audit report to:

Patient Safety Working Group

Medicines Safety Committee
Reaccreditation from KSS Deanery
Page 16 of 25
Director Medicines Management
& Pharmacy
Director Medicines Management
& Pharmacy
Director Medicines Management
& Pharmacy
Lead Technician Medicines
Management
APPENDIX 1
Criteria for referral for Second Level Medicines Reconciliation –
Pharmacy Consolidation
 It is proving difficult to source an accurate drug history
 Doses on a GP letter / repeat prescription are different from what the patient
is indicating they take.
 The 6-hour time limit for the first level admission led medicines
reconciliation has passed and there is a member of the pharmacy team on
the ward.
 There is a problem with a particular medication e.g. insulin.
 There is a concern regarding a patient’s concordance.
 The patient is taking foreign medication, which is difficult to identify.
 Nursing staff are unhappy with any aspect of the patient’s drug chart.
 Complex medical history
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APPENDIX 2
Criteria that may be used to identify patients requiring third level
medication review
In some circumstances it may be necessary to target patients for a detailed
medication review:











Patients for whom medicines may have contributed to current admission
Patients who have medical issues that suggest poor medicines management.
Patients who have physical issues that suggest poor medicines management
e.g. impaired sight, hearing, dexterity, mobility, swallowing, communication
(language or speech)
Patients who have social issues that suggest poor medicines management
e.g. isolation, financial problems, not coping at home (acopia).
Patients who have mental health issues that suggest poor medicines
management e.g. cognitive impairment, mental illness, confusion, learning
disabilities, disorientation
Patients who have had recent significant multiple changes to their preadmission medication
Patients who have been recently discharged from hospital
Patients who are taking high risk drugs e.g. digoxin, warfarin, lithium,
phenytoin, methotrexate, cytotoxics
Patients on polypharmacy (e.g., more than 6 medicines)
Patients who use or may require medication compliance aids devices to
support adherence
Patients taking opioids or other drugs with potential for abuse e.g.
methadone, benzodiazepines
This list is not entirely exhaustive or exclusive and there may be circumstances
where a patient does not fit any of the criteria above yet still needs a detailed
reconciliation.
Medicine Reconciliation In Adults Policy: Issue 3
Review date: May 2016
Page 18 of 25
APPENDIX 3
Checklist to support process of medicines reconciliation
It is not intended that this checklist be completed on paper and stored for every
patient, rather that it underpins training around MR and practically supports the
MR process and guides the documentation that must be added to the patient
medical record or the prescription chart.

















Patient details (full name, date of birth, hospital number, GP, date of
admission)
The condition for which the patient was referred (or admitted) plus details of
any co-morbidities
Known allergies and nature of the reaction (signed, dated, contact details and
documentation of sources used)
A complete list of all of the medicines currently being taken by the patient
Dose, frequency, formulation and route of all the medicines listed
Specific medication to ask about include
Insulin
Warfarin
Steroids
Inhalers
Eye drops
Topical preparations
Once weekly medication
As required medication
Clinical trials medication
Injections
Oral contraceptives
Hormone replacement therapy
Nebules
Home Oxygen
Recreational or detoxification medication
OTC medication
Herbal / homeopathic preparations
Additional information for specific drugs e.g. indication for medicines that are
for short-term use only (antibiotics and steroids), day of week of administration
for once weekly medication (bisphosphonates, methotrexate), indication and
dosage information for reducing or variable dose preparations.
Medication management in own home (include details of specific support e.g.
Nomad)
Sources used (minimum of 2) This should be documented in the patient’s
medical notes and on the front of the patient’s drug chart.
Name, date, signature and contact details of practitioner carrying out medicines
reconciliation.
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Review date: May 2016
Page 19 of 25
APPENDIX 4
Collecting information for medicines reconciliation
The ‘collecting’ step involves taking a medication history and collecting other
relevant information about the patient’s medicines. The information may come
from a range of different sources (some potentially more reliable than others).
The medication history should be collected from the most recent and reliable
sources. Where possible, information should be cross-checked and verified.
The person recording the information should always record the date obtained
and the source.
This section covers:
a) Taking a medication history
b) A checklist of questions that can support medicines reconciliation and help to
identify any problems
c) Sources that can be used to undertake medication histories
A) TAKING A MEDICATION HISTORY

Introduce yourself to the patient and explain the purpose of your visit.

Confirm with the patient whether they have any medication allergies or ADRs.
Check the nature of the reaction and document this information and the
source in the patient medical record and the drug allergy/hypersensitivity box
on the medication record chart:
-
If the patient has no known drug allergies/hypersensitivities, then
document as ‘NKDA’
If the patient is unconscious, unavailable, not mentally competent, or
you have concerns over the reliability of the information use other
sources to determine the allergy status.

Ask the patient if they have brought their own medicines and/or a list of their
medicines into hospital.

Ascertain what medicines the patient was using regularly at their previous
care setting prior to admission (see Section below on Sources for Medication
Histories).

Ask the patient for details of: medicine name, formulation, strength, frequency
of administration, indication and length of treatment for each medication.

Ask the patient if they have recently stopped taking any medication (within the
last month).

In addition to asking the patient about regularly prescribed medicines, also
check if the patient is using any inhalers, eye drops, topical preparations,
once weekly medications, injections, OTC medicines, herbal products, oral
Medicine Reconciliation In Adults Policy: Issue 3
Review date: May 2016
Page 20 of 25
contraceptives, hormone replacement therapy or has home nebules or home
oxygen – these are often forgotten or not considered medicines by patients.

Where the patient has been transferred from another care setting you may
need to check the medication history against the current medication record
chart or administration record from that setting. If the patient’s transfer has
been recent you may need to use your discretion and reconcile medicines
from prior to admission to the previous care setting.

The first source of documentation of a medication history on admission
should always be the patient’s medical record.

Ascertain the patient’s adherence to their prescribed medication regime. Ask
the patient/carer if they take/administer the medicines as labelled. Ask if they
use a compliance aid. Document any findings.
Note: Some patients are confused on admission to hospital and claim not to
be taking any medicines. If unsure as to the reliability of a patient’s answer,
the GP should be contacted for confirmation of the medication history and an
attempt to confirm the patient’s compliance made with an appropriate source
(i.e. family member, carer, etc) if possible.
Specific information should be collected about the following drugs:
The following points should be recorded in the patient’s medical notes
and prescription chart:

Warfarin
1. Indication, duration of treatment and target INR
2. Patient’s usual or most recent dose
3. Patient’s most recent INR result and date obtained where possible

Steroids
1. Indication
2. Most recent dose
3. Course details (i.e. maintenance or reducing dose) and length of
therapy where appropriate
Insulin
1. The drug, brand, administration device and dose should always be
checked and annotated on the prescription chart
2. For those patients that say that they have an insulin pen, clarify
between a pre-filled disposable pen and a penfill cartridge
3. For patients on variable dosing based carbohydrate load, an
appropriate dosing range should be stated


Oral contraceptives /HRT
1. These are not always considered as medicines by the patient and
should therefore be asked for.
2. Additional counselling may also be needed if antibiotics are started
when taking the oral contraceptive pill
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
Methotrexate
1. This is prescribed once weekly so the day of administration, strength
and number of tablets, if oral therapy, should be confirmed with an
appropriate source.
2. Check that this is correct on the drug chart and that the six days of the
week when the dose is not to be administered are crossed off.
3. Any concomitant folic acid prescriptions should also be asked about.

Bisphosphonates
1. The day of administration should be confirmed with an appropriate
source
2. Check that this is correct on the drug chart and that the six days of the
week when the dose is not to be administered are crossed off.
3. Ask the patient whether they take calcium preparations and confirm
which brand.

Inhalers
1. It is important to confirm the name, strength and type of inhaler.
2. Confirm if any compliance aids are used e.g. spacer device, haleraid®

Methadone
1. Check whether doses have been confirmed with the Drug Treatment
Centre (DTC), patient’s GP and community pharmacy.
2. Contact the community pharmacist to alert them of the patient’s
admission and determine the normal dispensing schedule and when
the patient last collected their methadone.
3. Ensure methadone is prescribed by number of milligrams not number
of millilitres (since two different strengths of solution are available).
This applies to ALL liquid medicines.
4. Patients do not usually get a supply of methadone on discharge.
5. The GP and community pharmacist/DDU contact will need to be
contacted pre-discharge to agree a plan of action.
6. Confirm formulation e.g. sugar free

Nebulisers
1. Identify whether the patient has own nebuliser machine and nebules at
home and document on the drug chart.
B) A CHECKLIST OF QUESTIONS TO SUPPORT
RECONCILIATION AND HELP IDENTIFY ANY PROBLEMS







MEDICINES
Does anyone help you with your medicines at home? If so, who? What do
they do?
Do you have any problems obtaining or ordering your repeat prescriptions
(NB: relative / carer might help)
Do you have a regular community pharmacy that you use?
Do you have problems getting medicines out of their packages?
Do you have problems reading the labels?
Some people forget to take their medicines from time to time. Do you? What
do you do to help you remember?
Some people take more or less of a medicine depending on how they feel.
Do you ever do this?
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

Most medicines have side effects. Do you have any from your medicines?
Specific medication related questions, such as have any medicines been
stopped recently or have any doses been changed recently?
C) SOURCES of MEDICATION HISTORIES
The following sources of drug histories are listed below in no order of preference,
as reliability can vary according to the situation. However it is usually necessary
to use two or more sources to establish an accurate drug history.

The Patient
- This is an important source, as the patient can 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 (POD’s)
- Encourage patients to bring in their medicines from home.
- Discuss each medicine with the patient 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.

Relatives/carers
- Patients may have relatives, friends or carers who help them with their
medicines.
- 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 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.

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
Ideally, a faxed list is preferable
- Be aware of ‘acute medicines’, ‘repeat medicines’ and ‘past
medicines’ on the receptionist’s screen.
- Always check when the item was last issued and the quantity issued.
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Page 23 of 25
-
-
Specific questioning may be needed for different formulations, for
example different types of inhalers (metered-dose, breath-actuated,
turbohaler), different calcium preparations (Calcichew®, Calfovit D3®,
Adcal D3®), or medicines which are brand specific (aminophylline,
theophylline).
It may be necessary for you to speak to the GP directly to clarify any
discrepancies.
Specifically ask whether there are any ‘Screen messages’. Some
medications are ‘hospital only’ and do not appear on the usual ‘repeat
list’.

Compliance aids e.g. Nomad, Dosette, Medisure, 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 etc.
- Consider contacting the community pharmacist to inform them of the
patient’s 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.

Compliance cards (green card)
- The chart should be checked through with the patient and the date of
issue noted.

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 (MARS) 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.

Hampshire Health Records
- Ensure the records have recently been updated, both the date stated
and when the medication was last issued.
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Review date: May 2016
Page 24 of 25
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
Mental health teams
Drug and alcohol service
Renal Dialysis unit
Other hospitals for clinical trials/unlicensed medicines
Oncology units
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.
Medicine Reconciliation In Adults Policy: Issue 3
Review date: May 2016
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