Rachel UrbanPharmacist Researcher Bradford Institute of Health Research/University of Bradfordr.l.urban@brad.ac.uk

AimsWhat exactly is Medicines Reconciliation?

Definition Patient Journey

Where does it go wrong?How can we put it right?

To look at the evidence and see what’s worked in practice

Discuss practical points to successful implementation

Background

What exactly is Medicines Reconciliation?IHI Definition“the process of creating the most accurate list

possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital” (Cambridge, 2008)

Patient enters

hospital

Drug History Taken, Chart

written

Validation of Drug History

Medicines Reconciliation

?

Patient enters Hospital

Drug history taken

Drug history verified

Dischargewritten

Discharge Information Communicated

Drug chart written

Patient moves wards

Patient counselled

Patient Discharged

Discharge Information processed

PharmacistTechnician

Via A&E Direct to Ward

Pre admissions

Doctor Nurse

Pharmacist

Doctor Pharmacist

NurseDoctor

Pharmacist

ITCHome Care Home

POD /MDSPatientEHR

Discharge infoCommunity Pharmacy

NHGP list

GPDNCPSSCare Home

GPDNCPSSCare Home

CP, GP, Admin Staff

Pharmacist, DN

Where does it go wrong?Medication history taking

Not using all available sourcesInaccurate prescribingLack of verification by pharmacy staffHandoverPatient counsellingCommunication

Not knowing what has been stopped and startedNot knowing why something has been stopped

startedTimeliness of discharge

What’s worked?EvidencePredominantly US studiesIsolated aspects of process

Predominantly secondary care Admission Discharge

Few primary careCare of the Elderly/ A&ERole of the Health Care Professional

PharmacistNurse

AdmissionA&E

Prescription chart initiated in A&E (Mills & McGuffie 2010) MR increased from 50-100% Rx chart from 6-80% Prescribing Error rate decreased from 3.3 to0.04

Encourage Ambulance to bring in PODS (Chan et al 2009, 2010) Percentage of medicines incorrectly prescribed

decreased from 18.9 to 8.8%

DischargeDischarge

Pharmacist discharge service (de Clifford et al 2009, Morrison et al 2004 )

Communication with community Pharmacists Pegrum et al , Cook 1995

Identification of discrepancies by CP (Paulino et al 2004)Counselling

Increases number of interventions (Karapinar 2009)Patient Information Proforma (Manning et al 2010)Decreases number of ADE after discharge (Schnipper

2006)Counselling on discharge by Community Pharmacists

(Hugtenburg et al 2009)

Primary CareLack of evidence on Med RecRobust repeat prescribing systemsEnsure systems for processing information

are robust

StandardisationForms/process

Pre-clinic questionnaire (Tattersall et al 2008)Med Rec form (Bedard et al 2010)

ITKiosk technology for DH taking (Lesselroth et al

2009)Nationwide on-line prescription records

(Glintborg et al )Natural language processing (Cimino et al )PAML builder (Turchin et al 2008)

Health Care Professional RoleHospital Pharmacist

Medication History taking (Nester and Hale 2002, McFadzean 1993 Carter et al 2006)

Presence of pharmacist on post-admission ward rounds (Fertleman et al 2005)

Pre-admission clinics (Kwan et al, Dooley et al 2008)Community Pharmacist

Faxing information to community pharmacies (Cook et al 1995, Cook and Choo 1997, Pegrum et al )

Counselling at discharge by community pharmacists (Hugtenburg 2009)

Community liaison pharmacist (Bolas et al 2004)

EducationImproving education for doctors

Bray-hall et al 2009, Lindquist et al 2008

Physician quality officerWalsh et al 2011

American Medical Association 2007 - Physicians Role in Medicines Reconciliation

RPSGB – Principles and Responsibilities for commissioners and providers plus minimum data set.

Common FactorsLeadership and Support

MD teamSimplification and standardisation of processClear policies and proceduresVisible processClarifying of Roles and ResponsibilitiesReporting and learning from errorsEducationFeedback and ongoing monitoring

Appropriate measures