Standard 4: Medication Safety

Medication reconciliation

Action 4.5

Clinicians take a best possible medication history, which is documented in the healthcare record on presentation or as early as possible in the episode of care

Intent

Patients and carers are actively involved in taking a best possible medication history (BPMH) as the first step in the process of medication reconciliation.

Reflective questions

What processes are used to obtain and record a BPMH in the patient’s healthcare record?

How does the health service organisation evaluate the quality of patient involvement in the process of obtaining a BPMH?

Key task

Implement a systematic process for obtaining the patient's actual medicine use and recording a BPMH.

Strategies for improvement

Hospitals

Complete a BPMH as early as possible on admission – this is the key first step of a formal process of medication reconciliation. At least two sources of information are needed to obtain and then confirm the patient’s BPMH – for example, the patient and their nominated general practitioner or community pharmacist.

A BPMH should be completed, or the process supervised, by a clinician with the required skills and expertise. Policies, procedures and guidelines for obtaining a BPMH should include:

  • A structured interview process
  • The key steps of the process
  • Documentation requirements (where and what should be documented, such as use of the MMP or equivalent; paper or electronic)
  • Roles and responsibilities of clinicians
  • Training requirements for clinicians
  • Involvement of patients and carers (links to Action 4.3).

Use a standard form for recording the BPMH. This may be the MMP, the section for medicines taken before presentation to hospital on the front of the NIMC or PBS HMC, or an electronic or paper-based equivalent. This creates ‘one source of truth’, and acts as an aid to reconciliation on admission, clinical handover, transfer and discharge.

Consider training requirements to ensure that clinicians with responsibility for obtaining a BPMH are sufficiently competent. Learning modules and instructional videos are available from various state, national and international organisations. These can guide clinicians on using a systematic approach to obtain and record an accurate and complete history of the medicines taken by patients at home, noting that specific techniques for taking a BPMH can influence its accuracy.

The BPMH and associated information should be easily accessible to all clinicians involved in managing the patient’s medicines, and used to reconcile against medication orders on admission, at transfers of care and on discharge. At the end of an episode of care, verified information should be transferred and communicated effectively to the next health service organisation to ensure continuity of medication management.1

Day Procedure Services

Complete a BPMH as part of the pre-admission screening process or as early as possible on admission. At least two sources of information are needed to obtain and then confirm the patient’s BPMH – for example, the patient and the referring clinician or community pharmacist.

A BPMH should be completed, or the process supervised, by a clinician with the required skills and expertise. Policies, procedures and guidelines for obtaining a BPMH should include:

  • A structured interview process
  • The key steps of the process
  • Documentation requirements (where and what should be documented, such as use of the MMP or equivalent; paper or electronic)
  • Roles and responsibilities of clinicians
  • Training requirements for clinicians
  • Involvement of patients and carers (links to Action 4.3).

Use a standard form for recording the BPMH. The BPMH can be documented on the ‘Medicines taken prior to presentation to hospital’ section on the front of the NIMC or in the preoperative medical record. It should be placed in a designated area of the patient’s healthcare record. This creates ‘one source of truth’, and acts as an aid to reconciliation on admission and on discharge.

Consider training requirements to ensure that clinicians with responsibility for obtaining a BPMH are sufficiently competent. Learning modules and instructional videos are available from various state, national and international organisations. These can guide clinicians on using a systematic approach to obtain and record an accurate and complete history of the medicines taken by patients at home, noting that specific techniques for taking a BPMH can influence its accuracy.

In day procedure services, a BPMH may be taken during the pre-admission process. Pharmacists or specialist services could be contracted by the day procedure service to provide training for other clinicians.

Examples of evidence

Select only examples currently in use:

  • Policy documents about obtaining and documenting a BPMH
  • Audit results of healthcare records for documentation of a BPMH
  • Evidence that BPMHs are documented in a standard place (hard copy or electronic), such as the MMP
  • Evaluation report on the quality of patients’ involvement in, and contribution to, the process of obtaining a BPMH
  • Training documents about taking and documenting a BPMH
  • Records of competency assessments of the workforce in taking and documenting a BPMH.
MPS & Small Hospitals

MPSs and small hospitals should have in place systematic processes for obtaining a patient’s actual medication use and ensuring that a BPMH is completed as early as possible on admission – this is the key first step of a formal process of medication reconciliation. At least two sources of information are needed to obtain and then confirm the patient’s BPMH – for example, the patient and their nominated general practitioner or community pharmacist.

A BPMH should be completed, or the process supervised, by a clinician with the required skills and expertise. Policies, procedures and guidelines for obtaining a BPMH should include:

  • A structured interview process
  • The key steps of the process
  • Documentation requirements (where and what should be documented, such as use of the MMP or equivalent; paper or electronic)
  • Roles and responsibilities of clinicians
  • Training requirements for clinicians
  • Involvement of patients and carers (links to Action 4.3).

Use a standard form for recording the BPMH. This creates ‘one source of truth’, and acts as an aid to reconciliation on admission, clinical handover, transfer and discharge.

Consider training requirements to ensure that clinicians with responsibility for obtaining a BPMH are sufficiently competent.

Action 4.6

Clinicians review a patient’s current medication orders against their best possible medication history and the documented treatment plan, and reconcile any discrepancies on presentation and at transitions of care

Intent

A formal, structured, multidisciplinary and timely process is in place for reconciling medicines against the BPMH and treatment plan, which involves patients and carers.

Reflective questions

What processes are in place to ensure that clinicians review their patients’ current medication orders against the BPMH?

How and where are discrepancies with a patient’s medicines documented and reconciled?

How are changes to a patient’s medicines, and the reasons for change, documented and communicated at transfer of care or on discharge?

Key task

Implement a formal structured process to ensure that all patients admitted to the health service organisation receive accurate and timely medication reconciliation on admission, at transfer of care and on discharge.

Strategies for improvement

Hospitals

Although specific aspects of medication reconciliation may be attributable to one professional group, medication reconciliation is everybody’s business, and a multidisciplinary approach is crucial to success.

Medication reconciliation may occur:

  • On admission – matching the current medicine orders with the BPMH, ideally within 24 hours of admission

  • During the episode of care – verifying that the current list of medicines is accurately communicated each time care is transferred and when medicines are recharted

  • On discharge – checking that medicines ordered on the discharge prescription match those on the discharge plan and the medicines list, and confirming that changes have been documented.

Prioritise medication reconciliation in patients who have a higher risk of experiencing medicine-related problems or ADRs, in a similar manner to prioritising or risk assessing patients for medication review (see Actions 4.10 and 4.12).

Review organisational policies, procedures and guidelines on medication reconciliation. These should include key steps of the medication reconciliation process and when these should occur (including at transfer of care and on discharge), roles and responsibilities of clinicians, training requirements for clinicians who are responsible for reconciling medicines, the involvement of patients and carers (links to Action 4.3), and documentation requirements, including where and what should be documented.

Review existing risk assessment criteria for patients who might benefit from medication reconciliation (links to Action 4.12).

Skills and training

Only clinicians with the requisite knowledge, skills and expertise should conduct medication reconciliation. These clinicians should be able to show competence in each of the steps of the medication reconciliation process.

Consider training requirements for clinicians who are responsible for reconciling medicines.

Day Procedure Services

This action will not be applicable for day procedure services that provide evidence that they are not changing or altering patients’ medicines during an episode of care.

Examples of evidence

Select only examples currently in use:

  • Policy documents about medication reconciliation on admission, at transitions of care and on discharge
  • Tool or form (hard copy or electronic) used for medication reconciliation
  • Audit results of documentation of medication reconciliation
  • Training documents about medication reconciliation and workforce training attendance records.
MPS & Small Hospitals

MPSs and small hospitals should implement a formal structured process to ensure that all patients admitted to the health service organisation receive accurate and timely medication reconciliation on admission, at transfer of care and on discharge.

Prioritise medication reconciliation in patients who have a higher risk of experiencing medicine-related problems or ADRs, in a similar manner to prioritising or risk assessing patients for medication review (see Actions 4.10 and 4.12).

Review organisational policies, procedures and guidelines on medication reconciliation. These should include key steps of the medication reconciliation process and when these should occur (including at transfer of care and on discharge), roles and responsibilities of clinicians, training requirements for clinicians who are responsible for reconciling medicines, the involvement of patients and carers (links to Action 4.3), and documentation requirements, including where and what should be documented.

Review existing risk assessment criteria for patients who might benefit from medication reconciliation (links to Action 4.12).

Only clinicians with the requisite knowledge, skills and expertise should conduct medication reconciliation. These clinicians should be able to show competence in each of the steps of the medication reconciliation process.

Last updated 3rd July, 2018 at 07:57pm
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References

Society of Hospital Pharmacists of Australia. SHPA quick guide: medication reconciliation. Melbourne: SHPA; 2013.