Medicines reconciliation

what is a medication history

a list of what the patient is currently taking, recently stopped taking and other changes made to their regime

when is a medication history needed

during any patient encounter

• GP appointment

• Admission to hospital

• Out-patient clinical appointment

• Pharmacy first consultation

• Request for OTC medicine / minor ailment advice

what is the importance of accurate medication histories 

• helps inform prescribing decisions

  • Avoid duplication of therapy

  • Avoid unnecessary polypharmacy

  • Avoid hazardous interactions

• Adverse drug reactions may explain patient’s symptoms

  • Contribute to approximately 16.5% of hospital admissions

  • May be delayed – e.g. flucloxacillin-induced cholestasis

• Some medicines need withholding prior to surgery

sources available for taking medication histories 

• Patient, relative or carer → patient may be interviewed, have their own list and / or be signed up to the NHS app

• Patient’s own medicines

• GP records / practice → can be accessed via the SCR or calling the surgery.  Sometimes the information will sent with a GP referral letter.

• Community pharmacist

• Nursing / residential home MAR sheet

• Recent discharge letter from hospital

• Out-patient clinic letter

• Transfer documentation from another hospital

what are the issues with patient/carer/relative interviews

• May not be able to remember everything

• May lie / fear Dr’s opinion?

  • Drugs with abuse potential

  • Borrowing” a friend’s / relative’s medicines

  • Self-adjustment of dosages

  • Poor / non-adherence

• Potential language barriers

• Safeguarding issues

When patients struggle to remember the names of their medicines and mispronounce them, be wary about correcting them as there are some similar sounding medicines

tips for conducting a patient/carer/relative interview

• Introduce yourself and explain purpose of consultation

• Positive patient identification

• Structured approach

• Open followed by closed questions

• Don’t intimidate the patient

• Don’t use medical jargon

• Don’t use leading questions (phrases used to prompt a specific/biased answer)

questions to ask during a patient/carer/relative interview

• Do you take any regular medication prescribed by your Dr?

• Does your Dr prescribe anything else for you, e.g. inhalers, eye drops, creams / ointments, patches, injections?

• Ask females about oral contraceptives or hormone replacement therapy as appropriate

• Ask about vaccines for relevant groups

• Ask about recent medication changes and why → changed by prescriber or patient

• Ask about recent short courses of medicines, e.g. antibiotics, steroids

• Do you take anything prescribed for anyone else (e.g. a relative)?

• Ask about medicines from internet pharmacies

• Ask about OTC / herbal / complimentary medicines

• Ask about recreational drugs use (substances taken for enjoyment)

• Confirm allergies and previous intolerances

• Ask about smoking and alcohol

give examples of interactions with some OTC medicines

• Fluconazole inhibits CYP450 enzymes

• Pholcodine linctus →  increases risk of anaphylaxis to neuromuscular blocking agents → withdrawal of all pholcodine containing products in 2023

dangers of herbal medicines

• ADRs well recognised with some e.g. hepatotoxicity with black cohosh

• Potential for interactions e.g. St John’s Wort

what is adherence and why do we need to enquire about it

the extent to which a patient takes their medication or follows recommendations from a healthcare professional

• Poor adherence may explain a patient’s hospital admission

• Need to identify early on → may avoid unnecessary additional medicines

• Some patients may only take medicines when symptomatic

• Potential opportunity for patient education

things to consider when patient brings in their own medicine

• Have they brought them all in?

• Are they this patient’s medicines?

• Check dates of dispensing

• Check label and packet match

• Check expiry date

multi-compartmental compliance aids / blister pack

a device designed to contain individual doses of medicines in separate compartments or blisters.

what do you need to consider when using GP records a a source

• Is it complete and up-to-date?

• No record of OTC or herbal meds

• What about medicines from specialists?

• Access via SCR, but:

  • Patients can opt out (may not have their consent)

  • England only

• Check date of last prescription issue

why are community pharmacies helpful

• for confirming if prescribed medicines have been dispensed

• for confirming what goes in multi-compartmental compliance aid

• when methadone last picked up

Patients often use same pharmacy but do not have to register with a single community pharmacist

what are considerations when using nursing / residential home MAR sheet as a source

reflects the items prescribed and administered in a nursing/care home

• Check all sheets have been sent

• Check carefully for stop dates

• Read directions carefully

• Has it been accurately transcribed from the prescription?

how useful are discharge letters as a source 

• useful if patient discharged in last couple of weeks

• Check with them if they’re aware of any changes between date of discharge and re-admission

• Was medicines reconciliation completed during that admission?

how useful are out-patient clinic letter as a source

a summary of a patient's visit to a hospital clinic, written by a healthcare professional to their GP and often copied to the patient

• May include information about medicines changes that have not been updated on GP record

• Information about medicines prescribed by specialist only

• May only focus on a single condition’s treatment

how useful is a transfer documentation form another hospital as a source 

Transfer to specialist centre and back

• Can see what the patient has been receiving before transfer

• Is documentation complete?

• Unfamiliarity with another system’s paperwork

• Was medicines reconciliation completed during admission at transferring hospital?

how many sources are needed

Usually recommend two sources, but have to consider 

• Acceptable to use one for a patient with no co-morbidities?

• Acceptable to use one for a patient who is knowledgeable about their medicines?

• May only have one source available at the time

• May need more for complex patients (e.g. those that get medicines from different clinics)

no source is 100%

considerations when patients are prescribed insulin

• Dose not stated on GP record, prescription or dispensing label

• Who administers it?

• If patient’s unsure of dose:

  • Relative / carer

  • District nurse (if they administer)

  • Recent discharge letter / admission notes

considerations when patients prescribed opiate substitution

• Must confirm dose with 2^nd source before prescribing in hospital

• Community drugs service:

  • Confirm drug, form, dose, frequency of pick-up, date of last pick-up, whether supervised consumption

  • Details of key worker

  • Details of any other medicines (e.g. benzodiazepines) prescribed by the service

  • They’ll usually contact community pharmacy to pause dispensing

  • Contact when patient discharged

considerations for patients with schizophrenia 

• May deny taking medicines (if have no insight into condition)

• Clozapine is hospital only prescription but only registered community pharmacies can dispense

• role of Community psychiatric nurse:

  • provide information on depot antipsychotics

  • If procyclidine listed on GP records, but no oral antipsychotics, question whether they are receiving depot antipsychotics administered elsewhere

what to include when documenting medication histories 

• Patient demographics

• Allergies / ADRs (+ description)

• Source(s) used to obtain history

• Current medication patient is taking – prescribed and purchased

  • Name, formulation, strength

  • Dose, frequency, timing

  • +/- indication, duration

• Medicines stopped / changed recently

• Vaccines?

• Potential or actual adherence problems

what is medicines reconciliation 

• process of identifying an accurate list of a person’s medicines and comparing them with the current list in use

• helps to recognise any discrepancies, and document any changes, resulting in a complete list of medicines

• Process followed depends on setting patient transferred to

when should you complete medicines reconciliation

• Upon admission to hospital

• Transfer between hospital wards (sometimes)

• Transfer between hospitals

• Upon discharge from hospital

• When GP practice receives hospital discharge or out-patient clinic letter

how does medicines reconciliation occur on admission

• take patients’ medicines list right early in their stay

• Obtain accurate medication history, often need at least two sources

• Compare with medicines prescribed on in-patient chart

• Identify discrepancies (differences found)

  • Document reasons if intentional

  • Resolve unintentional ones

why is medicines reconciliation important

• Reduces missed / wrong / delayed doses

• Potentially reduces ADRs

• Managing medicines in peri-operative period

• Influences decisions made and information sent to GP after discharge

Medicines reconciliation should be completed within 24hrs of admission

how do errors occur when taking medicines reconciliation

• Inaccurate / incomplete medication history documented

• Transcription errors between documented history and in-patient prescription

• Absent or incomplete documentation of reasons for changing pre-admission medicines

steps to ensure that a patient’s medications are accurately managed and documented when they are discharged from the hospital

• Discharge prescription written / transcribed → forms part of discharge letter

• Compare with medicines prescribed on hospital in-patient prescription (chart)

• Identify discrepancies and resolve errors (some medicines will be hospital only)

• Ensure appropriate course lengths and state if GP to continue

• communicate discharge letter to GP surgery → Need to explain changes made to pre-admission medicines and why new medicines started

steps to ensure  a patient’s medications are accurately managed and documented in primary care 

• GP surgery receives copy of discharge letter or out-patient clinic letter

• Medicines listed on letter compared with GP record

• GP record updated with new medicines to add to repeats and remove those discontinued in hospital

• Ensures GP records are accurate and up-to-date before next repeat prescription is issued

Medicines reconciliation should be completed in primary care within one week of GP practice receiving discharge information