Medicines Reconciliation Flashcards
What is Medication Reconciliation?
1) Is the process of obtaining an up to date and accurate medication list that has been compared to the most recently available information and has documented any
discrepancies, changes, deletions, additions
2) resulting in a complete list of medications, accurately communicated
when should medicines reconciliation happen?
1) Medicines should be reconciled at the transfer of care between different settings: e.g. hospital admission (planned and emergency)
2) hospital discharge
3) Movement between settings step up step down and ward/department transfer
4) Entry into residential/nursing care
what is the aim of medicines reconciliation on hospital admission?
the aim of medicines reconciliation when patients are admitted to hospital is to ensure that important medicines aren’t stopped and that new medicines are prescribed, with a complete knowledge of what a patients is already taking.
what are NICE/NPSA recommendations for medicines reconciliation?
1) policies in place for MedRec on admission.
2) specifying standardised systems for collecting and documenting information about current medications
- pharmacists are involved in medicines reconciliation as soon as possible after admission
- the responsibilities clearly defined
- strategies are incorporated to obtain information about medications for people with communication difficulties.
The reconciliation process involves the 3Cs. what are these?
1) Collecting
2) Checking
3) Communicating
explain the Collecting step of medicines reconciliation
1) involves taking a medication history or collecting relevant information about the patient’s medicines.
2) info from a range of different sources reliable?
3) most recent available information and the person recording the information should always record the date and the source of the obtained information.
explain the Checking step of medicines reconciliation
1) involves a critical appraisal of the information to verify that the medication and the doses are correct and that there re no omissions or duplications.
2) Where there appears to be a discrepancy between what the patient is currently prescribed, and what the patient is actually taking, this should be recorded too, and, where they can be established, the reasons for any variation.
explain the Communicating step of medicines reconciliation
1) This step could involve making changes to the patient record or prescription
2) Communicating the change to the patient, carer, or other healthcare professional or
3) organisation involved in the patient care e.g community pharmacist, care home staff
List the steps in a medicines reconciliation
1) Confirms patient’s name and DOB / address
2) Explain what you are going to do and why (Consent)
3) Asks about allergies and reaction if appropriate
4) Asks if you have brought your medication in with you, or a list of your medication
5) Asks how you take each individual item
6) Asks if you take any other medication (creams, patches, injections, eye drops) – must specify all
7) Asks if you take any medicines you buy from the pharmacy OTC/ shop/ internet
8) Asks if you take any herbal / medicines / vitamins / supplements /homeopathic / recreational drugs/ smoking
9) Asks if you have had any recent changes in your medicines ( e.g. anything recently stopped, started or dose changed)
list the sources of information for a medicines reconciliation
1) the patient
2) patient’s own drugs (PODs)
3) repeat prescriptions
4) relatives/carers
5) GP letter/surgery
6) reminder charts/devices
7) discharge summary
8) care home records
list some reliable sources of information
1) A computer print-out from a GP clinical records system
2) The tear-off side of a patient’s repeat prescription request
3) Verbal information from the patient, their family, or a carer
4) Medical notes from a patient’s previous admission to hospital
5) Patients own drugs
list some unreliable sources of information
1) Community pharmacy records
2) Medicine administration record (MAR) sheets
3) Care Plans
4) Care home managers
what information regarding allergies should be documented
1) nature of these
2) penicillins/cephalosporins
3) arachis oil = peanut oil
what information should be recorded for each drug when conducting a medicines reconciliation
1) name
2) dose
3) frequency
4) formulation
5) duration
6) indication
7) problems?
what should be done is Lamotrigine has been missed for 5 days
reiterate if missed > 5 days
what are PODs? and what caution should be taken
Patients' Own Drugs (PODs) check: 1) how much at home? 2) how many on repeat? 3) how managed at home? caution: 4) Is it their medicine? 5) Check PODs 6) NOMAD boxes – Stability? 7) Mixed tablets
list the Alarm Bell Medicines
1) warfarin
2) NOACs - dabigatran, rivaroxaban and apixaban
3) Steroids
4) methotrexate
5) Bisphosphonates
6) insulin
7) inhalers
list the Alarm Bell Conditions
1) drug misusers
2) clozapine
3) Antibiotics
4) Parkinson
5) Epilepsy
6) Chemotherapy
what should be checked with regards to warfarin
1) indication & target INR
2) date started and duration
3) dose and strengths
4) who monitors?
5) what time taken?
6) PODs
7) any problems?
what should be checked with regards to antibiotics
1) What’s the infection?
2) Where?
3) Course duration?
what should be checked with regards to steroids
recent courses?
long term?
chemo?
what should be checked with regards to Contraception /HRT
1) Missed pill
2) Interactions: antibiotics
what should be checked with regards to methotrexate
1) potentially toxic
2) weekly
3) dose
4) strength of tablets
5) day
6) folic acid- to reduce the side-effects of methotrexate
what should be checked with regards to Insulin
1) brand (and origin)
2) device
3) dose
what drugs are used to treat Parkinson’s disease ?
1) Co-Beneldopa (Madopar)
2) Co-Careldopa (Sinemet)
- they need to get it on time
what should be checked with regards to Bisphosphonates
1) daily or weekly
2) which day?
3) taking correctly?
4) calcium & vit D supplements?
what should be checked with regards to inhalers?
1) drug
2) strength
3) device
4) dose & frequency
what should be checked with regards to Drug misusers
1) methadone/Subutex
2) confirm doses with GP/DDU
3) inform prescriber/pharmacy
what should be checked with regards to Mental Health
1) Memory Clinic – Dementia medication
2) Depots
- when last given (date and site of injection)
- When due/ frequency
3) PRN medications
- Anticholinergics (e.g. procyclidine)
- Hypnotics (e.g. zopiclone)
4) Lithium
5) Clozapine : Dispensing pharmacy, frequency of blood tests, Bowel (laxatives)
- Patients who have had no clozapine for 48 hours must be re-titrated.
what should be checked with regards to Specialist services
1) Clinical trials
2) Chemotherapy
3) TB Meds
4) Gum clinic
- HIV meds
list some drugs which commonly cause dispensing errors
1) Aminophylline & Amitriptyline
2) Beclometasone & Betamethasone
3) Promazine & Promethazine
4) Penicillamine & Penicillin
with regards to the Continuity of treatment outline what the “five rights” are
1) right patient
2) right route
3) right drug
4) right dose
5) right time
