Medicines Reconciliation Protocol

Version 2

RATIFYING COMMITTEE Drugs and Therapeutics Group

DATE RATIFIED May 2021

NEXT REVIEW DATE May 2024

EXECUTIVE SPONSOR Chief Medical Officer

POLICY AUTHORS Principal Pharmacists

Deputy Chief Pharmacist

Specialist Pharmacy Technicians

Executive Summary:

• This protocol outlines the requirements and process relating to medicines reconciliation within the Trust. • Includes staffing skill mix, information sources to be used and documentation standards. • Identifies specific areas and medicines to be given further consideration.

If you require this document in an alternative format, i.e. easy read, large text, audio, Braille or a community language please contact the pharmacy team on 01243 623349

(Text Relay calls welcome)

CONTENTS

Page

1. Introduction 3

2. Scope 3

3. Definition 3

4. Duties and responsibilities 4-5

5. Medicines reconciliation process 6-9

6. Standards 11

7. Training 11

8. Monitoring compliance 11

Appendix 1 Medicines reconciliation template 12

Appendix 2 Medicines reconciliation flowchart 13

Appendix 3 Summary Care Record (SCR) process 14

Appendix 4 Summary Care Record (SCR) flowchart 15

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1. Introduction 1.1. Medicines reconciliation (MR) is the process by which medicines prescribed for patients on admission, corresponds to the medicines they were taking before admission, unless there is clear clinical justification for changing or discontinuing a medicine. 1.2. Historically, medicines reconciliation was performed by junior doctors on admission as part of the clerking process. In 2007, NICE and NPSA issued joint guidance highlighting the risks associated with medication prescribed on admission, with an unintentional error rate of 30-70% reported. POMH-UK shows that the Trust’s doctors undertake a drug history in 84% of patients but only find 4% discrepancies in those patients. 1.3. The guidance advised that pharmacy staff involvement in the medicines reconciliation process was associated with reduction in errors on admission, and advised that pharmacy staff should be involved with the medicines reconciliation process on admission to inpatient services as soon as possible, and ideally within 24 hours to acute services. 1.4. The medicines reconciliation process therefore aims to reduce the risk of harm to patients and reduce the risk to the Trust in terms of litigation and prolonged length of stay.

2. Scope 2.1. This protocol applies to all patients admitted to the Trust’s inpatient services, covering working age adult, secure and forensic, rehabilitation, learning disabilities, older people’s and young people’s services. If medicines reconciliation is carried out in the Crisis Resolution and Home Treatment (CRHT) team then this procedure applies 2.2. This protocol applies to all qualified medical, nursing, pharmacist and pharmacy technician staff, providing care to inpatients of Sussex Partnership NHS Foundation Trust. 2.3. This protocol should be read with reference to the Trust’s Medicines Code.

3. Definition 3.1. Medicines reconciliation is a process designed to ensure that all medicines that a patient is currently taking prior to admission is accurately recorded, documented and prescribed if still needed at point of admission and transfer. It includes: 3.1.1. Collecting information relating to medicines taken prior to admission, using the most recent and accurate sources of information to create a full and current list of medicines, including prescribed, over the counter, herbal and homeopathic medicines. 3.1.2. Checking that the medicines prescribed on admission are appropriate for the patient, and ensuring any discrepancies are documented, and actioned as necessary. 3.1.3. Communicating, through appropriate documentation, a full list of reconciled medicines. Including any changes, omissions and/or discrepancies.

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4. Duties and responsibilities 4.1. Medical Staff are responsible for: 4.1.1. Performing level one medicines reconciliation for patients admitted to the Trust, in line with the Trust protocol (see section 5.4). 4.1.2. Undertaking medicines reconciliation as soon as possible after patient admission, ideally as part of the clerking process, but within 24 hours of admission. 4.1.3. Clearly documenting if unable to complete medicines reconciliation, including the reasons and any further follow up actions. 4.1.4. Using appropriate sources of information. i.e. to use one, but ideally two information sources (refer to section 5). 4.1.5. Prescribing medicines in accordance with the medicines reconciliation process. 4.1.6. Documenting the patient’s allergy status on the drug chart and in carenotes, and recording allergy status as a clinical alert within carenotes. 4.1.7. Documenting the patient’s medicines list, sources used, and any medication changes (including reasons) within the patient’s carenotes record. To record under assessment tab. 4.1.8. Documenting and planning for any further measures required, for example: blood tests, unknown allergy status to be verified. 4.1.9. Acting on any further identified discrepancies as a priority. These may be communicated verbally or through the patient’s drug chart. 4.1.10. Document any alerts including allergies and vaccines (e.g. covid-19 vaccine, date, type and 1st/2nd dose) on care notes within the demographics and then alert section of carenotes.

4.2. Nursing Staff are responsible for: 4.2.1. The accurate and safe administration of medicines in accordance with the Trust’s Medicines Code and the Nursing and Midwifery Council (NMC) guidelines. 4.2.2. Reporting incidents. 4.2.3. Before administration of medicines ensuring that the allergy status is checked. 4.2.4. Supporting medical and pharmacy staff in undertaking medicines reconciliation, where appropriate, including accessing the patient’s Summary Care Record (appendices 3 and 4) or requesting a general practitioner (GP) summary and information 4.2.5. Document any alerts including allergies and vaccines (e.g. covid-19 vaccine, date, type and 1st/2nd dose) on care notes within the demographics and then alert section of carenotes. 4.3. Pharmacy Staff are responsible for: 4.3.1. Undertaking level two medicines reconciliation for patients admitted to the Trust, in line with this Trust protocol (see section 5.4).

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4.3.2. Undertaking the medicines reconciliation process as soon as possible after patient admission, ideally as part of clerking process, but within one full working day after admission. 4.3.3. Using at least two sources of information when undertaking medicines reconciliation (refer to section 5.2). 4.3.4. Documenting the medicines reconciled on the Trust approved template (see appendix 1) or electronic form on carenotes (when available). Ensuring sources used, full medicines list and allergy status are all recorded. This information should be typed. If unable to type, it must be completed in block capitals, and it must be legible and clear, using as many sheets as needed. 4.3.5. Uploading the approved template within 24hours in the “medication” tab of carenotes. 4.3.6. Ensuring medicines reconciliation and any outstanding actions are communicated and documented (in the patient’s notes and on their drug chart). 4.3.7. Document any alerts including allergies and vaccines (e.g. covid-19 vaccine, date, type and 1st/2nd dose) on care notes within the demographics and then alert section of carenotes. 4.3.8. Ensuring all discrepancies are recorded and communicated to the ward medical and nursing staff, including any agreed action plan. 4.3.9. Providing training on medicines reconciliation to ward and pharmacy staff where appropriate. 4.3.10. Undertaking Trust audit and providing assurance around quality and compliance to medicines reconciliation standards.

5. Medicines reconciliation process 5.1. Medicines reconciliation is the responsibility of all staff involved with the admission, prescribing, monitoring, administration, transfer and discharge of patients requiring medicines. It is a requirement to ensure that the drug chart is accurate as soon as possible after admission or transfer, to minimise the risk of harm to patients. 5.2. See appendix 2: medicines reconciliation process flowchart.

5.3. Collecting and checking information 5.3.1. Information relating to the patient’s medicines should be initially obtained from the patient (and/or carer) and collaborated (ideally) by at least two additional sources (as detailed below). 5.3.2. It should not be assumed that the medicines history documented in the admission notes or initial drug chart is accurate. These should be used as a guide only, as there can be errors with doses, formulations, product choice, omissions or discontinued medicines etc. 5.3.3. Patient consultation: Whenever possible, the patient should be the first source of information alongside the patient’s current drug chart and notes. An interpreter should be used where appropriate. A carer can also be asked if the patient is unavailable or unable to communicate information on their medicines.

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The following checklist can be used to aid the process.

5.3.4. Ensure patient consultation and/or discussion relating to medicines is fully documented within carenotes.

 Introduce yourself to patient/carer and explain what you are doing.  Confirm patient identity (photo / name / date of birth).  Clarify patient allergy status, including nature and severity of allergies. Document allergy status on the drug chart and in carenotes.  Ask what medicines they are currently prescribed by their GP, including names, strength, dose and frequency. Confirm with GP repeat or prescription form if available.  Ask if they have brought any medicines in with them, or if there is a relative that can bring all their supplies of medicines from their home.  Ask if they ever forget to take their medicines as prescribed, or if they have changed or stopped anything.  Ask if they are prescribed or given medicines by anyone else other than their GP, (eg. SMS sexual health, depot clinics).  Ask if they buy any medicines over the counter or use any herbal or complementary medicines.  Ask specifically about inhalers, eye & nose drops, patches, creams, injections and suppositories etc. if none are mentioned.  Ask if they have any problems when taking medicines at home.  Ask about adherence and side-effects with medicines. Consider impact of non-adherence or partial adherence on presentation and on current treatment (including doses prescribed and need to re-titrate).  Ask if they have their medicines in a blister pack or dosette box, and if so how these are filled.  Ask if they have any queries or concerns about their medicines.

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5.3.5. Appropriate sources of medicine information:

Source Suitability and benefits Cautions and advisory notes Patient relative or Encourage to bring in the patient’s own Be mindful of maintaining confidentiality. carer medication to hospital. May be helpful in Information provided should be confirmed establishing drug history or routine in with other sources community and unwanted medicines can be withheld at discharge. Summary Care Quick access to a summary of what is on Be wary of current medicines and acute or Record (SCR) the GP prescribing system. Provides full repeat medicines. Often will not include list of medicines prescribed by GP, secondary or tertiary care medicines. Be including dates last prescribed. wary of dates last administered recorded on (See appendix 3 and 4 for more details). the system. Where possible, get patient’s consent before accessing system. GP record or Full list of medicines from GP system, Be conscious of medicines prescribed by repeat prescription including dates last prescribed. other services or specialities. Be wary of time delay in requesting and receiving and impact on patient treatment. Carenotes patient Gives wider picture of patient current Information may not be accurate and is record care and previous history. Access to manually entered (not pulled from drug previous correspondence, admission and database). Be wary of dates of entries or discharge information. correspondence Patient’s own Encourage patients to bring in their own Check PODs with the patient and/or with the drugs (PODs) medicines (or if there is a relative or GP prescription record to assess patient’s including blister carer that can bring in on their behalf). adherence. Do not assume patient is taking packs. Re-use where appropriate and according medications as labelled. Also check to POD check dispensing dates against how much has (https://www.sussexpartnership.nhs.u been taken / how much remains. k/node/1628/attachment). Medicines Can be used as record of currently Check charts are labelled for patient, are Administration received medicines for patients in care current, and numbered. Record (MAR) homes or supported services. chart Inpatient drug Can be used if direct transfer and Check medicines reconciliation was chart (from provides an immediate picture of the performed during previous admission, and transferring or recent patient’s current episode of care. that all action points were resolved. admission) Previous transfer Can be used to give an understanding of Be mindful of last date and that medicines of care summary patient’s current medicines if recent, but may have changed in primary care between should be used with current GP and discharge and current admission patient information to give a clear picture GP referral letters Not accurate source, but can be used to indicate access to other services Community Can be used to support other sources of Patients may use several community Pharmacy information, for example clarifying blister pharmacies. Individual pharmacy record packs or over the counter medicines may not provide a comprehensive list for all of patient’s current medicines. Acute hospital or Correspondence and discharge Acute hospitals may have electronic private hospital summaries or copies or the drug charts prescribing therefore contact the pharmacy discharge should be checked. department if a copy is not sent with the TTOs medications should be checked. patient. Private hospitals should send a copy of the prescription/s. Specialist services: Correspondence should be checked, and Will be specific to individual treatments, and -Drug & alcohol if other prescribers or providers of not provide a comprehensive list of patient’s services medicines are identified they should be current medicines. Should always be -Mental health confirmed directly with service. contacted when oral cancer treatments have services (inc depot & been prescribed. clozapine) - Sexual Health or HIV - Tertiary centres - Anticoagulation - Specialist or community nurses

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5.3.6. Medicines requiring specific attention and consideration

Some medicines requires specific attention and consideration, as they are more prone to discrepancies, or where discrepancies can potentially cause greater harm / risk. Medication Considerations and specific points Clozapine Check and record:  Current dose, compliance before admission and smoking status of patient  Check patient clozapine (CPMS, DMS etc) record is transferred to ward and notify pharmacy clozapine service  Plan for next routine blood test is in place.  If the clozapine has been recently stopped and what the 'target' dose was prior to stopping. Long acting Check and record: injections  The LAI name  Current dose and frequency.  When the next dose is due.  Where the LAI is administered. Lithium Check and record:  Current dose and brand. Ask if patient has their lithium booklet  Check whether they are taking any medicines with the potential to interact (including OTC aspirin, ibuprofen and other NSAIDs).  Check if recent blood tests as per guidance and request lithium level if required. Warfarin Check and record:  Patient has their warfarin record or yellow booklet  Indication, duration of treatment, target INR  Patient’s normal and most recent doses  Latest INR – record and if outside reference range, escalate to pharmacist and doctor Steroids Prompt for patients with COPD or asthma:  Any recent courses (within last 6 months), dose and duration  If long term, annotate on drug chart, and ask if steroid card is available Insulin Check and record:  Type (human / bovine / pork), brand, device, and dose  For pens, clarify pre-filled pen or device and cartridges  Ask if patient has their insulin passport Methotrexate Usually prescribed once weekly. Confirm day of administration, strength and number of tablets taken. Ask if patient has their methotrexate booklet. Only 2.5mg tablets should be used. Check dose and day on chart is correct and cross off remaining six days each week. Check for any concomitant folic acid. Anaphylaxis pen Always:  Confirm and record patient’s current name of device and dose  Ensure the nursing team are informed as they may need risk assess the ward for allergy. Methadone Always:  Confirm and record patient’s current dose with alcohol and drug services, GP or community pharmacy. Contact community pharmacy to advise of any changes to administration schedule  Ensure methadone is prescribed by number of milligrams (not millilitres) due to availability of different product strengths.  If unable to confirm dose, refer to Trust Opiate Dependency guidance until maintenance dose can be confirmed with drug and alcohol services.  Patients do not usually get a supply on discharge, and previous collection arrangements are instead set up through Drugs and Alcohol services and local community pharmacy Tertiary centre or Always: specialist  Contact tertiary centre to confirm most recent dose and treatment plan treatment (e.g.  Record within patients’ notes the current dose as advised by tertiary centre HIV, oral  Request medicines supply from tertiary centre – NB, these are specialist and often high cost medications and responsibility for supply rests with tertiary centre. chemotherapy)  On discharge, return remaining supply provided by tertiary centre or refer patient back to tertiary centre to obtain further supplies. Parkinson’s Always: disease  Confirm and record patients’ current dose, brand and product strength, frequency and medications timings of doses with the patient/carer and prescriber.  Ensure patient has supply to avoid missed or omitted dose(s). Opioids Check and record:  Drug, formulation, brand, and dose that the patient has been taking.

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Oral Ensure these are specifically asked about during medicines reconciliation as are not always contraceptives considered “medicines” by patients. Bisphosphonates Usually prescribed once weekly. Confirm day of administration, strength and number of tablets taken. Check dose and day on chart is correct and cross off remaining six days each week. Inhalers & Check and record: nebules  Name, strength, brand and type of inhaler  Identify whether patient uses spacer and check their inhaler technique  Document equipment used on drug chart Vaccines Check and record:  Name, brand and date/s of vaccine  Which vaccine dose it is (i.e. 1st or 2nd)  Document vaccines details (type, date and 1st/2nd dose) on care notes within the demographics and then alert section of carenotes. 5.4. Communication and documentation 5.4.1. Level one medicines reconciliation 5.4.1.1. Record a clear and accurate drug history in the patient’s carenotes, including doses and frequencies of all medicines. 5.4.1.2. Record the information source(s) used. 5.4.1.3. Record the patient allergy status and include on the patient’s drug chart.

5.4.2. Level two medicines reconciliation 5.4.2.1. The medicines reconciliation and patient allergy status must be recorded both within the medicines history section of the patient’s drug chart, and within the patient’s notes. 5.4.2.2. The record within the patient’s notes should be within the electronic carenotes system, using either the embedded medicines reconciliation template (when available) or using the form in appendix 1. This must be uploaded to the medicines tab on carenotes within 24 hours of completion by pharmacy staff.

5.4.3. Discrepancies 5.4.3.1. Any discrepancies identified by the clerking doctor or during the level one medicines reconciliation process must be actioned as a priority. Any decision to change, omit or start medicines must be clearly documented (intentional discrepancies). 5.4.3.2. If any discrepancies are identified as part of the medicines reconciliation level two process, these must be raised as a priority with the ward doctor. Whether these are intentional or unintentional discrepancies needs to be clarified. Means of communication with ward doctor should be in accordance with local procedures and based on the urgency and risks associated with the omitted medicine(s). 5.4.3.3. Any decision to change medicines from the current medicines reconciliation must be clearly documented on the patient’s drug chart, and on the medicines reconciliation form or template (see appendix 1) 5.4.3.4. If any medication is identified as being required, but not prescribed (unintentional discrepancies), they must be escalated and actioned as a priority.

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5.4.3.5. If any medicine is identified as being required and is neither available from patient’s own medicines or ward stock, appropriate steps should be taken to obtain a suitable supply according to local procedure. 6. Standards Target Level one MR carried out within 24 hours of admission 90% Level one MR documented within carenotes 90%

Level two MR carried out within 24 hours of admission 60% Level two MR carried out by 5pm next working day after 90% admission Level two MR documented within Carenotes & on the 100% prescription chart Intentional changes are clearly documented 100% Unintentional changes are actioned within a timely 100% manner and clearly documented Medicine errors are reported within Trust’s incident 100% reporting system

7. Training requirements

7.1. Level 1 Medicines reconciliation is undertaken by medical staff: 7.1.1. Medical staff receive some training on drug history taking as students. 7.1.2. Additional training can be delivered locally 7.2. Level 2 Medicines reconciliation is undertaken by pharmacy staff: 7.2.1. Pharmacy technicians will have successfully completed the national accredited medication reconciliation course prior to undertaking unsupervised level two medicines reconciliation, and will undergo annual internal competency assessment (in-line with national standards). 7.2.2. Where a pharmacy technician or student has not completed the national accredited medication reconciliation course then they can be complete the level two medication reconciliation but it must be checked by a qualified technician or pharmacist prior to it being uploaded to carenotes. 7.2.3. Pharmacists receive thorough competency-based training on medicine history taking as part of undergraduate and pre-registration training and are deemed competent. Standards will be subject to further competency-based assessment as part of undergraduate training. 7.2.4. Pharmacists undertake the role without specific accreditation.

8. Monitoring compliance 8.1. Audit of compliance against the standards set within this protocol will be undertaken annually. 8.2. Continuous monthly audit of level two (pharmacy staff) medicines reconciliation timings is recorded and submitted as part of national data collection. 8.3. Continuous monitoring and reporting of errors associated with medicines reconciliation errors takes place.

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Appendix 1: Medicines reconciliation template form MEDICINES RECONCILIATION (Version 4 – May 2021) NOTE – Medicines Reconciliation is reflective of medicines on admission and will be superseded during episode of inpatient care. Admission date: Med Rec completion Allergy/Sensitivity (describe symptoms): Name: date and time: (Or NKDA) DOB: Pharmacist/Technician (Name in block caps) Sources used (at least 2): GP/SCR/Discharge summary/ NHS No: PODs/Patient/Carer/Clozapine service

Location: Med Rec within 24 hrs? Y/N Does patient have Blister Packs Y/N Chemist name and Phone number: GP Surgery: Admitted following overdose Limited quantity by GP Adherence issues: Smoking status: Reported side effects with medications: Y/N No of days …… (Re-titration required?) Current medicines (including inhalers, eye drops, patches, creams, injections etc., herbal, homeopathic, Drug chart Comments correct (Recent dose or drug changes) alternative meds, vitamins, CBD oil, OTC, not prescribed) (Clozapine bloods due) Before/on admission Name, Route, Frequency, Dose (Depot/LAI due) (Information obtained from the sources above then compared to the drug chart) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Additional Information: Previous medicines – especially clozapine, depots/LAIs (name, route, frequency, dose, when stopped and the reason) Vaccines (especially covid-19) must be recorded and an alert added on carenotes (see section 4.3.7)

If a continuation sheet (PTO) is needed please upload to carenotes & staple hardcopies together

Appendix 2: Medicines reconciliation process flowchart

This process should be followed by medical and pharmacy staff where medicines reconciliation service is provided, for all inpatient units.

Patient admitted to hospital Patient Admitted to Hospital

Sources of Information

Collecting information. The following is not in order of

preference. Refer to the full protocol Level One Medicines Reconciliation Record a clear and accurate drug history for further details regarding sources in the patient’s carenotes, including doses of information: & frequencies of all medications and • Check ‘medication’ tab to information source(s) used. Record allergy ensure no recent history status in carenotes & on drug chart. completed • Patient/carer Level Two medicines reconciliation Medication history, including allergy status • Patients Own Drugs (PODs) collected from patient / carer and • Summary Care Record confirmed with at least two reliable (SCR) sources. • GP repeat prescription form • GP faxed medicines history • Discharge prescription or Level Two Recording inpatient chart from transferring hospital

Pharmacy staff to record within Carenotes • MAR sheet (drug chart) from using the electronic template (when care/nursing home available) or to complete and upload the Medicines reconciliation record form (appendix 1) to the “Medication” tab within 24 hours.

Annotate the front of the inpatient drug chart with “Medicines reconciliation Communicating Information complete”, sign and date. Any decision to change a medication a

patient has been taking should be recorded in the patient notes, and on the Checking Information Medicines reconciliation template, giving the reason for the change. Verify the medicines reconciliation list

against the current inpatient drug chart. Ensure any discrepancies are accounted for and actioned appropriately, by Prescribers must communicate all documenting on the front of the drug medication changes and reasons for chart & in carenotes. Communicate to change to GPs at point of discharge,

ward medical staff. using the Trust’s discharge notification paperwork.

Appendix 3: Summary Care Record (SCR) process

• Obtain patient consent to access SCR when possible. • Click onto "clinical applications". • Click "National Health service portal". • Log in with your smart card. • On NHS applications, click onto "Launch summary care record (SCR)". • Enter NHS number & click "find". Alternatively, enter patient details & click "find". • Click on "view SCR" in top right-hand corner. • Click "yes" if patient has given you consent to access record. • Click "emergency access" if no consent given, and enter under explanation "Patient best interest, treatment continuity", then click "continue". • Check date at top of page of when SCR created. This must be within the last 3 months. • Check 1st box for any allergies & adverse reactions recorded. • Check 2nd box for any acute medicines recently prescribed. Also, check for any inhalers, oral contraceptive pill, steroids, depots etc. that may have been prescribed previously. • Check 3rd box for current repeat medicines ensuring that the last issued date is recent. Be aware that the last issue date may be e.g. 3 months old but the quantity prescribed reflects this. Also, check for any specialist medication information that may be listed here e.g. clozapine, depots. • Check the reason for medicines under each item as this can give important information, e.g. blister pack patient. If the quantity is for only 7 days, this may also suggest a blister pack patient. If blisters are provided, the community pharmacy details can be found on the "GP & care provider" tab. • Check 4th box for any discontinued medicine. This may be useful for clarification purposes. • If SCR details are not recent (within 3 months) or clarification is needed regarding any medicines, please contact the GP. GP details can be found under the "GP & care provider" tab.

No SCR available

• If patient does not have a SCR available, then you must ring/email the GP to request a medicine history, including allergies. GP details can be found under the "GP & care provider" tab.

If the GP details on SCR do not match carenotes this needs to be amended - please seek further assistance if you are not aware of the process to do this.

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Appendix 4: Summary Care Record (SCR) flowchart

This process should be followed by medical and pharmacy staff where medicines reconciliation service is provided, for all inpatient units.

Log in to SCR with smartcard smsmsmsmartcar

Check date at top of page of Discontinued medicines: when SCR created. This may be useful for clarification This must be within the last 3 purposes. months.

If SCR details are not recent or clarification is needed regarding any medicines, please contact the GP.

GP details can be found under the Current Repeat Medications: "GP & care provider" tab. Check the last issued date as this may not be recent. Be aware that the last

issue date may be e.g. 3 months old but the quantity prescribed reflects this. Allergies & adverse reactions. Also, check for any specialist medicines information that may be listed here e.g. Record any information along clozapine, depots, and HIV medicines. with any known effects or symptoms. Check the reason for medicine under each item as this can give important information, e.g. Blister pack patient. If the quantity is for only 7 days, this may also suggest a blister pack patient. Acute medications: If blisters are suggested, contact the Check for any medicines recently community pharmacy whose details can prescribed. be found on the "GP & care provider" tab. Check for any previous prescriptions for inhalers, Oral contraceptive pill, steroids or depots.

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