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An Evaluation of Medicines Reconciliation and its Role in

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									Rachel Urban
Pharmacist Researcher
Bradford Institute of Health Research/
University of Bradford
r.l.urban@brad.ac.uk
Aims
 What 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      Medicines
Drug History     Reconciliation?
   Via A&E          Doctor                                                  Nurse
Direct to Ward                                              Doctor
                    Nurse                                                   Doctor
     Pre                                                  Pharmacist
                  Pharmacist                                              Pharmacist
 admissions


Patient          Drug history     Drug         Patient    Discharge      Patient
enters           taken            chart        moves      written        counselled
Hospital                          written      wards
                                                            ITC
                  POD /MDS                                               Patient
                                                           Home
                    Patient             Drug history                     Discharged
                                                           Care
                      EHR               verified           Home
                 Discharge info                                        Discharge
                  Community                                            Information
                                                         GP
                   Pharmacy                                            Communicated
                                        Pharmacist       DN
                       NH
                                        Technician       CP
                     GP list
                                                         SS
                                                         Care Home       Discharge
                                                                         Information
                                                                         processed


                                                                       CP, GP, Admin
                                                                            Staff
                                                                       Pharmacist, DN
Where does it go wrong?
 Medication history taking
    Not using all available sources
 Inaccurate prescribing
 Lack of verification by pharmacy staff
 Handover
 Patient counselling
 Communication
    Not knowing what has been stopped and started
    Not knowing why something has been stopped started
 Timeliness of discharge
What’s worked?
Evidence
 Predominantly US studies
 Isolated aspects of process
     Predominantly secondary care
         Admission
         Discharge
     Few primary care
 Care of the Elderly/ A&E
 Role of the Health Care Professional
    Pharmacist
    Nurse
Admission
 A&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%
Discharge
 Discharge
    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 Care
 Lack of evidence on Med Rec
 Robust repeat prescribing systems
 Ensure systems for processing information are robust
Standardisation
 Forms/process
    Pre-clinic questionnaire (Tattersall et al 2008)
    Med Rec form (Bedard et al 2010)
 IT
    Kiosk 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 Role
 Hospital 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)
Education
 Improving education for doctors
    Bray-hall et al 2009, Lindquist et al 2008


 Physician quality officer
    Walsh 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 Factors
 Leadership and Support
    MD team
 Simplification and standardisation of process
 Clear policies and procedures
 Visible process
 Clarifying of Roles and Responsibilities
 Reporting and learning from errors
 Education
 Feedback and ongoing monitoring
    Appropriate measures

								
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