•MEDICATION

RECONCILIATION
•A SYSTEMATIC PROCESS
TO REDUCE ADVERSE
MEDICATION EVENTS

•BY DR.MARWA FAWZI

• 10-67% of medication histories contain at least one
error1
• Incomplete medication histories at the time of
admission have been cited as the cause of at least
27% of prescribing errors in hospital 2
• The most common error is the omission of a
regularly used medicine3
• Around half of the medication errors that happen in
hospital occur on admission or discharge 4
• 30% of these errors have the potential to cause
harm3,5
BY THE END OF THIS SESSION
YOU WILL BE ABLE TO
• • Define medication history & its interview?
• • Know the goals of the medication history interview.
• • Acknowledge the Importance of medication histories.
• • What to be documented(procedure)?
• • Practice the Interviewing process
• - Enumerate the Information sources.
• - Know QUESTIONS to ASK.
• -Apperciate medication History Taking TIPS
NSW EXAMPLES - MEDICATION ERRORS

Aspirin and clopidogrel

Patient suffered
ceased in ICU and not May have
sudden cardiac
recommenced when contributed to
arrest resulting in
patient transferred to patient’s death
death
ward

Patient prescribed Patient suffered pre- Caused

ramipril 1.25mg daily, syncopal episode, temporary
medication chart was was transferred to harm and
rewritten as ramipril HDU and required required
12.5mg daily noradrenaline intervention

Patient initiated on Caused

new cardiac Patient became temporary
medication, acutely unwell and harm and
discharged with no was re-admitted required
summary or medicine intervention
MEDICATION MANAGEMENT
PATHWAY

Decision to Procure
prescribe
Transfer of medicine
Record medicine
verified information
order/prescription

Monitor of
Review of
response
Patient medicine order

Administration of
Issue of medicine
medicine
Provision of
Distribution &
medicines
storage of
Quality audit information
medicine
and review
MEDICATION RECONCILIATION

• A process to reduce adverse

medication events by:
- Ensuring patients receive all
intended medicines
- Mitigating common errors of
transcription, omission,
commission and duplication
- Ensuring accurate, current
and comprehensive
medication information
follows patients on transfer
and discharge
WHAT IS MEDICATION HISTORY?

• A medication history is a detailed, accurate and complete account of all

prescribed and non-prescribed
• medications that a patient had taken or is currently taking prior to a newly
initiated institutionalized or ambulatory care.
• It provides valuable insights into patients’ allergic tendencies, adherence to
pharmacological and non-
• pharmacological treatments, social drug use and probable self-medication with
complementary and alternative medicines.
• Interviewing a patient in collecting the data medical history is called medication
history interview
GOALS

• The goal of medication history interview is to obtain information on aspects of

drug use that may assist in over all care of patient.
• The information gathered can be utilized to: ?Compare medication profiles with
the medication administration record and investigate the discrepancies.
• ?Verify medication history taken by other staffs and provide additional information
where appropriate.
• ?Document allergies and adverse reactions. ?Screen for drug interactions.
• ?Assess patient medication compliance. ?assess the rationale for drug prescribed.
• ?Assess the evidence of drug abuse. ?Appraise the drug administration techniques.
• ?Examine the needs for medication aids. ?Document patient initiated medication
administration.
WHAT IS TO BE DOCUMENTED?

• To review current medical treatment and identify suitable additional treatments, medical
professionals will require complete and reliable
• medication history. Research has established that in routine practice,
• pharmacist provide the most accurate history when compared to other health
professionals. It is an important role that pharmacists are well prepared to fulfill.
• A well prepared, structured approach helps to obtain relevant complete information and
avoid omissions. The fallowing information is commonly recorded:
• Currently or recently prescribed medicines.
• OTC medication. Vaccinations.
• Alternative or traditional remedies. Description of reaction and allergies to medicines.
• Medicines found to be ineffective.Adherence to past treatment courses and the use of
adherence aids
MEDICATION RECONCILIATION
4 SIMPLE STEPS TO IMPROVE PATIENT SAFETY

1. Collect a comprehensive medication history

2. Confirm the accuracy of the history

3. Compare the history with prescribed

medicines

4. Supply accurate medicines information

1. WHAT IS A BEST POSSIBLE
MEDICATION HISTORY (BPMH)?
• An accurate and complete medication
history, or as close as possible

• Uses at least one other source of

medicines information to verify

• More comprehensive than a routine

primary medication history
1. COLLECT A BPMH

• Gather an accurate as possible

medication history, using a
combination of sources of
medicines information:
- Patient/carer interview
when possible
AND/OR
- Other sources of
medicines information
e.g. community
healthcare provider
2. CONFIRM THE ACCURACY OF THE
HISTORY
• Verify the obtained information
- Use a secondary source to
confirm the interview
information OR
- Use two or more sources of
information to obtain and
verify the medication history

• Explore inconsistencies between the

different sources
• The collecting and confirming steps
may occur in succession or
concurrently
SOURCES OF MEDICINES
INFORMATION
• Sources may include:
- Patient/carer interview (wherever possible)
- GP medication list, referral letter, phone
call
- Patient medication list
- Community pharmacy dispensing history
- Residential Aged Care Facility (RACF)
medication chart
- Patient’s own medications, prescriptions or
dose administration aids
- Previous hospital discharge summary
3. COMPARE THE HISTORY WITH
PRESCRIBED MEDICINES
• Use the BPMH when determining the
medications to be prescribed on admission:
- Decide and document the plan for each
medicine e.g. to continue, change,
withhold or cease
- Check the medicines that have been
prescribed follow the plan
- Compare pre-admission and current
medications at every transfer of care
4. SUPPLY ACCURATE MEDICINES
INFORMATION
• Between wards, hospitals and at discharge
consider:
- Are all medicines prescribed still
relevant?
- Do any pre-admission medicines
withheld/changed need to be
recommenced/changed back?
- Are the changes, including reasons
clearly documented?
- Is the list complete and clear for your
patient, your team and the next care provider?
NSW Medication Management Plan (MMP)

Prompts for:
- Dose
- Frequency
- Indication
Area to record - Duration
medicines taken - Recently ceased
prior to - Recently changed
presentation - Sources of list
- Checklist

A TOOL TO FACILITATE MEDICATION

RECONCILIATION
Dr’s Plan column enables comparison
with the medication chart at
Medication
admission
Chart
MMP
RECONCILIATION COMPLETE ON
ADMISSION

Tick reconcile
column
once complete
IDENTIFYING AND TRACKING
ISSUES

Area to record:
- Identified medication
related problems
- Action required
- Person responsible
- Result of action
ASSISTING DISCHARGE

As well as containing a list of

the patient’s pre-admission
medications for comparison at
discharge the MMP can:
- Capture medication changes
during admission
- Capture comments e.g.
medication administration
and supply requirements
- Provide a discharge checklist
- Identify patients for home
medicines review
THE SAFETY AND QUALITY HEALTH
SERVICE STANDARDS
• Criteria linked to medication reconciliation
- The clinical workforce taking an accurate
medication history…
- The clinical workforce reviewing the
patient’s current medication orders…and
reconciling any discrepancies
- Ensuring a current comprehensive list of
medicines, and the reason/s for any
change, is provided to the receiving
clinician and the patient during clinical
handovers
INTERNATIONAL

• The World Health

Organisation (WHO)
names medication
reconciliation as one of its
‘High 5’ patient safety
solutions
KEY POINTS

• A BPMH results in safer prescribing

• Documenting a BPMH and plan

- Improves communication between the health care team
- Reduces error, confusion and re-work
- Reduces time and error at discharge

• Reconciling at admission, ward/hospital transfer and discharge

reduces medication errors and patient harm

• Providing accurate information at transfer/discharge results in

safe ongoing care
MEDICATION HISTORY STEPS

•Let's practice
INTERVIEWING THE PATIENT

• • Introduce yourself
• • Inform PATIENT of reason for you being there
• • Inform PATIENT of importance of maintaining a current
• medication list in chart
INFORMATION SOURCES

• • Patient
• • Family or Caregiver
• • Medication Vials / Bubblepacks
• • Medication List
• • Community Pharmacy
• • Medication Profile from other facility
• • DPIN (Drug Programs Information Network)
QUESTIONS TO ASK
• • Which community pharmacy do you use?
• • Any allergies to medications and what was the reaction?
• • Which medications are you currently taking:
• • The name of the medication
• • The dosage form
• • The amount (specifically the dose)
• • How are they taking it (by which route)
• • How many times a day
• • Any specific times
• • For what reason (if not known or obvious)
• What prescription medications are you taking on a regular or as
needed basis?
• • What over-the-counter (non-prescription) medications are you
taking on a regular or as needed basis?
• What herbal or natural medicines are you taking on a regular or
as needed basis?
• • What vitamins or other supplements are you taking?
MEDICATION HISTORY TAKING TIPS

• • Balance open-ended questions (what, how, why,

• when) with yes/no questions
• • Ask non-biased questions
• • Avoid leading questions
• • Explore vague responses (non-compliance)
• • Avoid medical jargon – Keep it simple
• • Avoid judgmental comments
MEDICATION HISTORY TAKING TIPS

•
• Various approaches can be used:
• • 24 hours survey (morning, lunch, supper, bedtime)
• • Review of Systems (head to toe review)
• • Link to prescribers (family physician, specialists)
• • Prompt for: – Pain medications – Stomach medications – Medications for
bowels – Sleeping aids – Samples
• • Prompt for:– Eye or ear drops, nose sprays – Patches, creams &
• Ointments – Inhalers (puffers) – Injections (needles)
MEDICATION HISTORY TAKING TIPS

• • If medication vials available:

• • Review each medication vials with patient • Confirm content of bottle
• • Confirm instructions on prescription vials are current
• • If medication list available: • Review each medication with patient •
Confirm that it is current
• • If bubble packs available:
• • Review each medication with patient
• • Confirm patient is taking entire contents
ADDITIONAL QUESTIONS TO EXPLORE

• Effectiveness/Compliance
• • Are any of the medications causing side effects?
• • Have you changed the dose or stopped any medications
• because of unwanted effects?
• • Do you sometimes stop taking your medicine whenever
• you feel better?
• • Do you sometimes stop taking your medicine if it makes
• you feel worse?
PATIENT EDUCATION

• • Encourage ownership
• • Educate client to bring medications from home at each
• appointment
• • Educate client to carry a list of current medications
• (prescription and OTC)
• • Encourage family members/ caregivers to become
• involved
• • Encourage one pharmacy
RECONCILIATION AND DOCUMENTATION

• • Upon discovering a discrepancy

• • Update the list if minor (eg OTC taken as needed)
• • Include medications prescribed by other physicians
• (eg specialist)
• • Inform physician if client is not taking as prescribed
• • Document in the client’s chart
• • The date MedRec completed and initial on the
• medication reconciliation status record
• • Any pertinent information in the progress notes
• Watch the video and train
yourself
REFERENCES

1. Tam V, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE.

Frequency, type and clinical importance of medication history errors at
admission to hospital: a systematic review. CMAJ 2005;173:510-5.

2. Dobrzanski S, Hammond I, Khan G, Holdsworth H. The nature of hospital

prescribing errors. Br J Clin Govern 2002;7:187-93.

3. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN,

Etchells EE. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med 2005;165:424-9.

4. Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication

reconciliation in the acute care setting: opportunity and challenge for
nursing. J Nurs Care Qual 2005;20:95-8.

5. Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting

medication errors at hospital admission and discharge. Qual Saf Health Care
2006;15:122-6.
QUESTIONS?
THANK YOU