MEDICINES RECONCILIATION PROCEDURE

August 2019

This policy supersedes all previous policies for Reconciliation of on Admission Policy.

Document title Procedure for Medicines Reconciliation

Document PHA73 reference Document Clinical category Relevant to Clinical staff

Date published September 2019

Implementation September 2019 date Date last August 2019 reviewed Next review August 2022 date Document Chief Lead

Contact details Email: [email protected] Telephone:

Accountable Medical Director director

Approved by Drugs and Therapeutics Committee (Group):

Approved by (Committee)

Document history Date Version Summary of amendments

Aug 2019 6 Routine review

Feb 2015 5 Routine review

Membership of the policy development/ Neelam Sharma, Chief Technician review team

Consultation Audrey Coker, Lead Mental Health Pharmacist, Caroline Lawrence, Specialist

Pharmacy Technician

DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet.

I MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF:PHA73

Contents Page

1 Introduction 3

2 Aims and objectives 3 3 Scope of the procedure 3

4 Responsibilities 3

5 Procedure of medicines reconciliation 6

6 Discharge prescriptions 8

7 Documentation 8

8 Dissemination and implementation 9

9 Training requirements 9

10 Monitoring and audit arrangements 9

11 Review of procedure 9

12 Associate documents 9

Appendix 1: Sources of histories 10

Appendix 2: Medicines reconciliation flowchart 13

Appendix 3: List of critical medicines 14

Appendix 4: Template for medicines reconciliation and template 15

Appendix 5: Equality impact assessment tool 18

II MEDICINES RECONCILIATION PROCEDURE: August 2019: REF: PHA73 1 Introduction

1.1.1 Medicines reconciliation should take place when patients are admitted to , transferred to other units or wards within a hospital or to another hospital. It can also take place when patients are discharged from hospital1.

1.1.2 Medicines reconciliation should take place within twenty four hours of a patient’s admission. In exceptional cases, medicines reconciliation may not have been completed within 24 hours e.g. over the weekend but should be completed as close to the admission date as possible (within 72 hours).

1.1.3 A full list of patients current medication should be obtained from at least two reliable and up-to-date resources.

1.1.4 Level 1 medicines reconciliation takes place for all newly admitted patients and when they are transferred from another unit or ward. This should be conducted by the admitting doctor within 24 hours of admission or transfer.

1.1.5 Level 2 medicines reconciliation is conducted by pharmacy in which the level 1 medicines reconciliation is verified and checked against the current prescription.

1.1.6 Communication of any changes, omissions and discrepancies should be discussed with the doctor straight away and resolved and correctly prescribed as clinically appropriate. These should be documented in the electronic notes system.

2 Aims and objectives

2.1.1 To describes the process for medical, pharmacy and staff to reconcile patients’ medicines.

2.1.2 To ensure medicines prescribed on admission correspond to those that the patient was taking before admission, unless changes have been made for a specific clinical reason.

3 Scope of the procedure

3.1.1 This procedure applies to all clinical staff involved in the handling of medicines for patients admitted or transferred to trust services.

4 Responsibilities

4.1 Admitting doctor

4.1.1 The admitting doctor is responsible for conducting the initial level 1 medicines reconciliation, documenting the details on Carenotes an d prescribing on the chart. This should be completed during clerking and within 24 hours of admission.

3 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

4.1.2 The initial medicines reconciliation (level 1) is admission or transfer led and will be conducted by the admitting doctor as part of the clerking process. Level 1 medicines reconciliation involves recent and accurate sources of information to create a full and current list of medicines. At least two different sources should be used (for example, GP repeat prescribing record supplemented by information from the patient and/or carer). Refer to appendix 1 for full list of sources and appendix 2 (flow chart of the process).

The patient’s current list of medication should then be entered in the progress notes under the heading ‘medicines history’ as part of clerking process.

4.1.3 Pharmacy should be informed of the new admission as soon as possible so that a level 2 medicines reconciliation check can be done. Pharmacy can also identify new patient admissions via the electronic patient notes system or by using the Bed Manager’s report.

4.1.4 The doctor should seek prescribing advice from a senior doctor or pharmacist (on call service when out of normal working hours) where medicine reconciliation is not possible and there are potential clinical risks for the patient if medicine doses are omitted (refer to appendix 3 for list of critical medicines).

4.2 Pharmacy

4.2.1 A pharmacist/pharmacy technician should be involved in the medicines reconciliation process for all patients, as soon as is possible after admission.

4.2.2 A level 2 check should be completed & entered in the progress notes under the heading ‘medicines reconciliation’.

4.2.3 A level 2 check involves taking the basic reconciliation information obtained in level 1 and checking or verifying this list against the current prescription chart ensuring any discrepancies are accounted for and rectified appropriately. See appendix 2 (process flow chart).

4.2.4 Check allergy status is recorded in the appropriate section of the medicines chart and electronic clinical record.

4.2.5 The pharmacist is responsible for ensuring that the initial medication history taken is verified, any discrepancies resolved, or confirmed as intentional, and correctly prescribed on the medicine chart.

4.2.6 An accredited pharmacy medicines management technician (MMT) can conduct a level 2 medicines reconciliation check. The MMT should inform the team pharmacist when completed & must raise any discrepancies with the pharmacist immediately.

4.2.7 The pharmacist is responsible for ensuring that the initial medication history has been completed, any discrepancies resolved, or confirmed as intentional, and medication is correctly prescribed on the medicine chart.

4.3 Nursing Staff

4.3.1 Where nursing staff are involved in compiling a list of the medication regime the 4 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

patient has been taking, using the sources detailed below, they should record the information in the progress notes entitled ‘medicines reconciliation’. The nurse should inform the doctor and pharmacist so that the list can be checked and prescribed on the patient’s medicine chart (i.e. level 1 medicines reconciliation and level 2 check, can be completed).

4.3.2 Nurses should appropriately address any discrepancies highlighted by the patient during medicines administration. This may include withholding medicines until confirmation from the prescribing team has been received.

4.4 Ward Staff

4.4.1 Any information scanned to the ward regarding the patient’s current medication should be added to the notes straight away (e.g. uploaded onto electronic patient record). An entry should also be made in the main section of the notes (e.g. in progress notes) documenting when it was received and where it has been filed.

5 Procedure of medicines reconciliation

5.1.1 Refer to appendices 1 & 2 for further information on taking a medication history and sources of information.

5.1.2 If the patient has been transferred from another unit or ward within the Trust, check that the medicine reconciliation has been completed. If medicines reconciliation has been completed then make an entry in the progress notes stating that a medicines reconciliation (level 1 & 2) has been completed & make reference to the date on which it was completed, so it can easily be located.

5.2 Core information required for medication history

5.2.1 The following information should be obtained during medicines reconciliation:

5.2.2 Any medication allergies/sensitivities and serious adverse reactions to a medicine. This should include the name of the causative agent and a brief description of the reaction/side effect if possible. This should be documented in the appropriate section of the medicine chart and in the notes e.g. in progress notes and alerts section on electronic patient records system. Or if the patient does not have any medication allergies document NKDA (no known drug allergies) in progress notes.

5.2.3 For each current medication, the following information should be obtained and documented: the medicine name, route, dosage, frequency, timing, formulation and indication of treatment. For patients on depot medication (or regimes other than daily) the last date administered and next due date should be documented.

5.2.4 Adherence issues. This is especially important to identify if dose re-titration is needed e.g. clozapine, carbamazepine, lamotrigine, methadone, buprenorphine. Additional information for specific medicines, see appendix 4.

5.2.5 Over the counter or alternative medication that the patient is taking e.g. St John’s Wort.

5 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

5.2.6 Current use of any illicit drugs e.g. cannabis or legal highs and alcohol use.

5.2.7 If the patient is a smoker, as this can affect medication plasma levels e.g. clozapine or olanzapine.

5.2.8 Refer to appendix 4 for a checklist of information to be obtained during medicines reconciliation. This checklist may be used as a guide whilst completing medicines reconciliation, but the checklist itself does not need to be documented in the notes.

5.3 Level 1 medicines reconciliation

5.3.1 Level 1 medicines reconciliation should be carried out for all newly admitted patients or on transfer to other unit/ward, by the admitting doctor within 24 hours of admission.

5.3.2 The GP should be contacted to request a medication history and to let the GP the patient has been admitted to the ward. The information may be taken verbally initially and then followed up with a documented version. The patient’s permission to access their Summary Care Record can also be requested from the patient to obtain the GP records.

5.3.3 Check the patient’s notes for any details about their current medication. This could include recent past discharge notifications/summaries or a referral form or letter. Consideration must be given to the date of the recorded information and to the fact that subsequent changes may have been made to the medication.

5.3.4 Where possible, double check with the patient/carer as to how he/she takes the medicines, as this may not be the same as what is actually prescribed.

5.3.5 Patients/carers should be encouraged to bring all their current medicines (prescribed and non-prescribed) into hospital which should be checked during the medicines reconciliation process. Check if they have a compliance aid (refer to appendix 1 for further guidance on this). Refer to the Trust standard operating procedure for Patients’ Own Drugs (PODs). Check with the patient what he/she is actually taking. For other resources that can be used to obtain an accurate history refer to appendix 1.

5.3.6 There is a checklist in appendix 4 that details the information that should be checked and documented in the notes during medicines reconciliation. This checklist may be used as a guide when completing level 1 and 2 medicines reconciliation.

5.3.7 At least two sources of information should be used to verify the patients current medication details. See appendix 1 for sources of information. Care needs to be taken with regards to patient confidentiality.

5.3.8 The patient’s GP (where registered) should always be contacted to confirm current medicines, although if the patient is admitted when the G.P or other sources are closed an accurate medication record may not be possible at this point.

5.3.9 Particular attention must be given to confirming the prescription details of opioids for analgesia or substitution treatment of opiate dependency. For opiate dependent patients on substitution treatment (e.g. methadone, 6 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

buprenorphine) two sources should always be used to confirm the dose (via substance misuse services, the community pharmacy, GP, crisis team and assertive outreach team).

5.3.10 Attention must be given if the patient was being seen by the crisis team or the assertive outreach team as these teams may have very recently changed medication or altered doses.

5.3.11 Discrepancies may be found after checking each of the above sources. All identified discrepancies or difficulties in completing the process should be documented in the patient’s notes. Discrepancies should be clarified, with for example the GP. There may be times that patients have not been complying with their prescribed medication and it would dangerous to prescribe their usual medicines without a period of assessment and review. In such cases, the reason for not prescribing the medicines should be noted in the patient’s notes.

5.3.12 All current medicines should be prescribed on the inpatient medicine chart where clinically appropriate. Medicines should be prescribed as per Trust Medicines Management policy available on Trust intranet. Any intentional changes made to the patient’s medication should be documented with reasons in electronic patient records. The patient’s medication history (with sources used) should be clearly documented electronic patient records.

5.3.13 If an accurate medication record cannot be obtained at this point, the doctor should seek prescribing advice from a senior doctor or pharmacist (on call service when out of normal working hours) where medicines reconciliation is not possible and there are potential clinical risks for the patient if medicine doses are omitted.

5.3.14 The doctor can make a clinical decision in regards to what is prescribed for the patient which does not conform with the medicines reconciliation. It may not be possible to get a full history from an unwell or uncooperative patient who may still require a prescription to be written. Every effort should be made to ensure such a prescription is safe and appropriate to the needs of the patient and that a full history is obtained at the earliest opportunity. Details of the exceptional circumstance and subsequent decision to treat must be recorded in the patient’s notes.

5.3.15 Pharmacy should be informed of any new patient admissions as soon as possible so that a level 2 medicines reconciliation check, clinical screening and any necessary supply of medicines can be completed.

5.4 Level 2 medicines reconciliation

5.4.1 A level 2 medicines reconciliation should be carried out as soon as possible.

5.4.2 The pharmacist or accredited MMT should check the level 1 medicines reconciliation by following the procedure for the level 1 check outlined above. The checklist in appendix 4 may be used as a guide. This list should be verified against the current prescription chart to ensure the medicines have been prescribed correctly.

5.4.3 Ensure allergy status has been recorded in the appropriate sections of the medicines chart and clinical notes. On electronic patient records system, known

7 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

allergies should be documented in the progress notes and alerts section. If there are no known medication allergies then record this in the progress notes.

5.4.4 Immediate communication with the doctor should take place if any discrepancies are found. Any discrepancies identified must be resolved or confirmed as intentional changes with the doctor, immediately.

5.4.5 Patients who fulfill the following criteria should be referred to the ward pharmacist:-

 Medication related admission e.g. an overdose.

 Complex medical history.

 Patients prescribed lithium, phenytoin, carbamazepine, clozapine, warfarin.

 Patients prescribed buprenorphine or methadone.

 Patients prescribed more than six medicines.

 Patients recently discharged from hospital.

5.5 Communication difficulties

5.5.1 For patients who do not speak English or who have communication difficulties, additional resources to facilitate communication may be used. Medication patient information leaflets (PILs) where available, should be given to the patient.

6 Discharge prescriptions

6.1.1 To facilitate future medicines reconciliation, all changes to the patient’s admission medication should be documented fully in the discharge prescription (TTA). Medical staff should complete the discharge prescription and ensure accurate information on medicines is transferred to the GP or the next provider of care.

6.1.2 The ward pharmacist or covering pharmacist should check:

 That medicines prescribed are a complete and accurate record.

. That any changes to the patient’s medication are fully documented.

 That any pharmaceutical needs identified have been acted upon.

6.1.3 Once the ward pharmacist is satisfied that these have been completed, they should sign and date that they have screened the TTA.

6.1.4 Once the discharge prescription has been checked by a pharmacist and dispensed, a copy of the patient’s discharge prescription is sent to the GP surgery and/or the next unit involved in the patient’s care to ensure the continuity of care. A copy should also be given to the patient.

7 Documentation

8 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

7.1.1 The following should be documented in electronic patient records: sources of medication information, information found, discrepancies found and action taken as a result. If there is a decision not to prescribe medicines due to e.g. a recent period of non-compliance, the decision should also be documented in the notes.

8 Dissemination and implementation arrangements

8.1.1 This document will be circulated to all managers who will be required to cascade the information to members of their teams and to confirm receipt of the procedure and destruction of previous procedures/policies which this supersedes. It will be available to all staff via the Trust intranet. Managers will ensure that all staff are briefed on its contents and on what it means for them.

9 Training requirements

9.1.1 Pharmacy technicians involved in medicines reconciliation must complete an accredited medicines reconciliation training programme.

10 Monitoring and audit arrangements

Elements to Lead How trust Frequency Reporting Acting on Change in be monitored will arrangements recommendations practice and monitor and Lead(s) lessons to be compliance shared Medication MSO No. of Quarterly Drugs and Drugs and Review of incidents incidents Therapeutics Therapeutics policy; reported Committee Committee implementation Level 2 Pharmacy Audit / Monthly SPM meeting DTC practices and medicines Pharmacy procedures. reconciliations KPI Re- audit. undertaken by Give feedback the Pharmacy to prescribers

11 Review of the procedure

This policy will be reviewed in August 2022.

12 Associated documents

. Medicines Management Policy

. Patients Own Drugs SOP

. Clozapine treatment guideline

. Prescribing guidelines for the management of bipolar affective disorder 9 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

. Depot Antipsychotic Medication: Guidelines for Prescribing and Administration

Appendix 1

Sources of Medication History

The following sources of medication history are listed below in no order of preference, as reliability can vary according to the situation. Two or more sources should be obtained to establish an accurate medication history, one of which should be from the GP surgery.

. The Patient - 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. - If the patient brings in a repeat slip, note this may include medicines which have been stopped. . Patients’ Own Drugs (PODs) - 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. - Check the date of dispensing. - 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. - 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 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 medication history with the patient, relative/carer or GP surgery. . Summary Care Records - A full list of acute and repeat prescriptions by the GP. - A list of the discontinued medicines. 10 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

- The dates may not be reliable. - Need permission to access from service user. - The service user may not have been collecting though the GP has been issuing the prescriptions. - Possible to identify which community pharmacy the service user usually collects from. . Care Integrated Digital Record (CIDR) - Information similar to SCR. - Restricted to patients living in Camden. - May be used if not possible to obtain permission to access from service user e.g. if they are too unwell to give permission. . Medical Interoperability Gateway (MIG) - Information similar to SCR. - Restricted to patients living in Islington. - May be used if not possible to obtain permission to access from service user e.g. if they are too unwell to give permission.

. GP surgery - Ideally, a scanned list is preferable, especially if the receptionist appears to be having problems pronouncing the medicine names. See appendix 5. - Be aware of acute medicines, repeat medicines and past medicines on the GP record. - Always check when the item was last issued and the quantity issued. - Specific questioning may be needed for different formulations, for example different types of inhalers (metered-dose, breath-actuated, turbohaler), different calcium preparations (Calcichew®, 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 are ‘hospital only’ and do not appear on the usual repeat list. . Adherence aids e.g. Dosett Venalinks, Medimax. - These may be filled by the community pharmacist, district nurses, relatives or patient.

. Medication reminder charts - The chart should be checked through with the patient and the date of issue noted. . Recent hospital discharge summary or recent TTAs - 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 medication history. . Residential/ records e.g. Medication Administration Record sheets. - Useful and accurate source for a medication history. - Usually sent in with the patient. - Handwritten lists from homes should be used with care as they may have transcription errors.  Recent CPA records – may be useful as a supplementary source of information.

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: 11 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

 Anticoagulant  Clozapine  Depot clinic  HIV clinic  Crisis teams and assertive outreach teams  Community  Specialist Nurses e.g. heart failure/asthma nurse  Drug and alcohol service  Renal Dialysis unit  Other for clinical trials/unlicensed medicines  Service transferring a patient

Where possible, double check with the patient/carer as to how he/she takes the medicines, as this may not be the same as actually prescribed.

12 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

Appendix 2

Medicines Reconciliation Flowchart

Level 1 Medicines Reconciliation Level 2 Medicines Reconciliation

Admitting clinician (within 24 hours) Pharmacist/ MMT (within 72 hours) Newly admitted patient/ transfer to other unit / Newly admitted patient/ transfer to other unit/ ward ward

Obtain medicines history & allergy status from GP -Check the information obtained in the level 1 reconciliation & that at least 2 sources have been used. - Ensure allergy status is recorded appropriately. Medicines history: Obtain a full accurate list of - Collect information from additional sources if current medication. Collect information from at necessary to verify current medication list. least 2 of the most recent sources such as: - Contact GP if „GP request to Share Information - GP* - Patients notes Form‟ has not been sent or if a response has not - Patient/carer - PODs yet been received. - Specialist clinics - Crisis Teams/AOTs

*Always contact if patient has a GP. Check the medicines reconciliation list against the current prescription chart. - Make an entry in the patient’s electronic notes under progress notes titled ‘medicines history’ & list all of the current medication stating sources used (see checklist appendix 2) & allergy status. Communicate any changes, omissions & - On front of medicines chart tick „medicine discrepancies with the doctor asap. Ensure any history‟ box & complete allergy status box. discrepancies are resolved & correctly prescribed - Record allergy status in notes on the medicine chart as clinically appropriate

Prescribe current medications on inpatient medication chart as deemed clinically appropriate & complete allergy status box. - Make an entry in the patient’s electronic notes under progress notes titled ‘pharmacy Check medicines reconciliation list against current medicines reconciliation’. inpatient prescription - State that medicines reconciliation conducted on admission (level 1) has been verified as correct OR if there are any discrepancies or omissions clearly document the changes & document a full Communicate any changes. Medicines stopped, accurate list all of the current medications. started or doses intentionally changed should be documented in the patients‟ progress notes. - Tick „medicines reconciliation‟ box on front of medicines chart. Check allergy status completed.

If it is not possible to confirm medication details & there are potential clinical risks for the patient (see critical medicines list) if doses are missed, a senior doctor or pharmacist (on call service when out of normal working hours) should be contacted.

13 MEDICINES RECONCILIATION PROCEDURE: AUGUST 2019: REF: PHA73

Appendix 3

1. LIST OF CRITICAL MEDICINES Reducing harm from omitted and delayed medicines in hospital (NPSA/2010/RRR009) Medicine doses are often omitted or delayed in hospital for a variety of reasons. Whist these events may not seem serious, for some critical medicines or for patients with chronic conditions delays or omissions can cause serious harm or death. The procedures outlined below are applicable to all medicines but are of particular importance to critical medicines.

Omitted / Delayed Doses Critical Medicines Clinical management:  Contact and discuss with doctor & pharmacist immediately on  Anticoagulants awareness of omission / delay.

 Clozapine Documentation:  Insulin  Clinical notes - reasons why medicine omitted/delayed, actions taken  Methadone and patient’s condition.  Medicine chart – appropriate omission code.  Buprenorphine Reporting:  Complete incident report via datix.

Doctor  Ensure medicines correctly prescribed in time for next due dose.  Inform pharmacy and nursing staff medicine prescribed.

Nurse  Ensure medicines ordered from pharmacy promptly in time for next due dose.  Ensure medicines administered at appropriate time.

Pharmacy  Ensure medicines clinically screened in time for next due dose.  Ensure medicines supplied promptly in time for next due dose.

On Admission  Ensure medicines reconciliation conducted .

On Transfer  Ensure all individual patient non-stock medicines accompany the patient

During Admission  Ensure medicines initiated during admission are correctly prescribed.  Ensure treatment plan documented in notes.  Check if relevant protocols & guidance (including acute trust protocols where appropriate) are available and refer to them.

CONTACT PHARMACY FOR ADVICE ON POSSIBLE HARM FROM OMITTED/DELAYED DOSES OF ANY MEDICINE – Including out13 of hours.

Appendix 4

Template for medicines reconciliation & checklist

The following tools may be used to aid the medicines reconciliation process.

1. Template for Medicine Reconciliation recording in client’s progress notes. The following may be cut and paste title into the client’s progress notes as an aid to recording medicines reconciliation for an individual service user.

PATIENT DETAILS GP, community pharmacy or nursing home details)

MEDICINES RECONCILIATION: Source of information: 1- 2-

ALLERGIES: (NB. Record if NKDA & Add known allergies to alerts)

ADVERSE REACTIONS TO MEDICATION / HYPERSENSITIVITIES

LIST ALL MEDICINES PRIOR TO ADMISSION (Name, formulation, strength, dose, frequency & timing, indication):

OPIOIDS PRESCRIBED:

DATE & TIME OF LAST DOSE:

ADHERENCE ISSUES:

OTC or COMPLIMENTARY MEDICATION:

ILLICIT DRUGS:

ALCOHOL USE:

SMOKING STATUS:

DISCREPANCIES IDENTIFIED & ACTION TAKEN:

15

2. Check list of core information to be collected for medicines reconciliation. This checklist may be used as a guide whilst completing medicines reconciliation to ensure all core information is collected, does not need to be documented in the notes.

Core information checklist to be documented in patients’ progress notes  List any medication allergies. Known allergies should be added in the appropriate section in notes e.g. under alerts on Carenotes. If there are no known allergies document ‘NKDA’ on the medicines chart & in the progress notes. List any known adverse reaction to medication Check Smoking status (can affect medication plasma levels e.g. clozapine) List all the current medicines including inhalers, eye drops, topical preparations, once weekly medication, injections, OTC medicines, herbal/alternative medicines, oral contraceptives, HRT, home nebules or home oxygen – these are often forgotten by patients. For each medicine, state the:  Name, route, strength, dose, frequency & timing (e.g. mane, nocte, tds), formulation (e.g. tablet, liquid, dispersible), indication (see example below)  Depot medication– state date last administered & next due date  Antimicrobials; state indication & duration of treatment.  See appendix 2 regarding specific information to be collected with individual medicines i.e. warfarin, steroids, insulin, methotrexate, methadone. Use at least two reliable recent sources (see appendix 1) & state which sources used. State any compliance adherence issues (check if medicines need to be re-titrated) List any over the counter medicines (e.g. bought from pharmacy) List any herbal/ alternative medicines List any illicit drugs

Specific information should be collected about the following medicines:  Warfarin - The following points should be recorded on the medicine chart for patients taking warfarin:  1. The details of the clinic monitoring the anticoagulation.  2. The date of the next appointment.  3. Indication, duration of treatment and target INR.  4. Patients usual or most recent dose  5. Quantity of tablets that the patient has at home.  6. Whether patient has an anticoagulant “yellow” book  7. The date of the last INR and the result.

 Steroids - It is important to obtain an accurate history particularly for patients with asthma or COPD, IBD or arthritis. - Ask about any recent courses (within past 6 months) and if so, how many and for how long (whether they were short 5-7 day courses or reducing courses). - For those on long-term steroids this should be annotated on the medicine chart so that treatment is not abruptly stopped.

15  Insulin - The type (human, bovine or pork), brand, administration device and dose should always be checked and annotated on the medicine chart. - For those patients that say that they have an insulin pen, clarify between a pre- filled disposable pen and a penfill cartridge. - The dose must be written as units‟ and not abbreviated to “u‟ or “iu‟.

 Methotrexate - This is prescribed once weekly so the day of administration, strength and number of tablets taken should be confirmed with the patient. - Check that this is correct on the medicine chart and that the six days of the week when the dose is not to be administered are crossed off. - Any concomitant folic acid prescriptions should also be asked about. - Ask to see the patients monitoring booklet.

 Methadone/ Buprenorphine - Check whether doses have been confirmed with the specialist substance misuse clinic, patient’s GP or community pharmacy. Where possible Two sources should always be used to confirm the dose. - Check a urine drug screen has been undertaken. - 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. This will avoid double scripting.  The date and time of the last dose given should be confirmed.  If the patient has missed three doses, the prescription may need to be re-titrated (see the Trust inpatient opiate policy). The Substance Misuse Service should be contacted for information.  Ensure methadone is prescribed by both number of milligrams and number of millilitres (since two different strengths of solution are available). This applies to ALL liquid medicines.  The dose of methadone or buprenorphine should also be written in words and figures on the prescription chart. - Patients should not get a supply of methadone on discharge. - The substance misuse clinic (and substance misuse worker), GP, community pharmacist and will need to be contacted pre-discharge to agree a plan of action.

Opioid analgesics

Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicine prescribed for the patient with the prescriber or through medication records. If possible, two sources should always be used to confirm the dose.

Oral contraceptives/HRT - may not be considered medicines by the patient and therefore should be asked for.

Antibiotics – indication and duration.

Biphosponates The day of administration should be confirmed with the patient and annotated on the prescription chart, if once a week dosing. Delete the days the patient will not be taking a dose. The patient may take calcium tablets as well. Check which brand. Inhalers - Confirm the name, strength, dose and type of each inhaler.

16

Lithium Check which brand the patient is prescribed. Most patients are prescribed Priadel, but there are a few patients that are not. Patients should remain on the same brand as the bioavailability of brands differ. Confirm the patient’s current dose. Check the date and result of the last lithium test. Check whether any medicines that may interaction with lithium (prescribed or over the counter). Check if the patient has a lithium record booklet and last records – dose, lithium levels, target levels, renal and thyroid functions.

Depot Injections The date of the last injection, name, dose, frequency, next due date and site of injection should be checked with the relevant Community Team or GP surgery.

Clozapine Check when the patient last took a dose. If it is more than 48 hours, a re-titration regimen will need to be agreed with the consultant and prescribed. Confirm when the patient last had an FBC, the result and the frequency of blood tests.

Where a patient has missed medication for four days or more, then CPMS will need to be contacted and a different frequency of blood tests set by the service.

The contact number for CPMS is 0845 769 8269 (Out of Hours: 01276692504). CPMS will require the patient’s full name, CPMS number or date of birth in order for the member of staff to answer queries.

Herbal Remedies/ Over the Counter Medicines – Ask the patient about these as some may be clinically relevant e.g. St John’s Wort, laxatives and antihistamines for insomnia.

Overdoses If prescribed medicines were taken, it is important to confirm that the patient is medically cleared and that it is deemed safe to restart prescribed treatment. Confirmation will be required from the discharging A & E department before restarting treatment and in some cases confirmation of current U & Es, liver function tests and serum drug levels will be necessary.

17

Appendix 5: Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group

less or more favourably than another on the basis of:

Race no

Ethnic origins (including gypsies and travellers) no

Nationality no

Gender no

Culture no

Religion or belief no

Sexual orientation including lesbian, gay and no bisexual people

Age no

Disability - learning disabilities, physical disability, no sensory impairment and mental health problems 2. Is there any evidence that some groups are no affected differently? 3. If you have identified potential discrimination, n/a are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to no be negative? 5. If so can the impact be avoided? n/a 6. What alternatives are there to achieving the n/a policy/guidance without the impact? 7. Can we reduce the impact by taking different n/a action?

18