Medicines Reconciliation

Question 1

What is Medication Reconciliation?

Answer 1

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

Question 2

when should medicines reconciliation happen?

Answer 2

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

Question 3

what is the aim of medicines reconciliation on hospital admission?

Answer 3

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.

Question 4

what are NICE/NPSA recommendations for medicines reconciliation?

Answer 4

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.

Question 5

The reconciliation process involves the 3Cs. what are these?

Answer 5

1) Collecting
2) Checking
3) Communicating

Question 6

explain the Collecting step of medicines reconciliation

Answer 6

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.

Question 7

explain the Checking step of medicines reconciliation

Answer 7

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.

Question 8

explain the Communicating step of medicines reconciliation

Answer 8

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

Question 9

List the steps in a medicines reconciliation

Answer 9

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)

Question 10

list the sources of information for a medicines reconciliation

Answer 10

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

Question 11

list some reliable sources of information

Answer 11

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

Question 12

list some unreliable sources of information

Answer 12

1) Community pharmacy records
2) Medicine administration record (MAR) sheets
3) Care Plans
4) Care home managers

Question 13

what information regarding allergies should be documented

Answer 13

1) nature of these
2) penicillins/cephalosporins
3) arachis oil = peanut oil

Question 14

what information should be recorded for each drug when conducting a medicines reconciliation

Answer 14

1) name
2) dose
3) frequency
4) formulation
5) duration
6) indication
7) problems?

Question 15

what should be done is Lamotrigine has been missed for 5 days

Answer 15

reiterate if missed > 5 days

Question 16

what are PODs? and what caution should be taken

Answer 16

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

Question 17

list the Alarm Bell Medicines

Answer 17

1) warfarin
2) NOACs - dabigatran, rivaroxaban and apixaban
3) Steroids
4) methotrexate
5) Bisphosphonates
6) insulin
7) inhalers

Question 18

list the Alarm Bell Conditions

Answer 18

1) drug misusers
2) clozapine
3) Antibiotics
4) Parkinson
5) Epilepsy
6) Chemotherapy

Question 19

what should be checked with regards to warfarin

Answer 19

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?

Question 20

what should be checked with regards to antibiotics

Answer 20

1) What’s the infection?
2) Where?
3) Course duration?

Question 21

what should be checked with regards to steroids

Answer 21

recent courses?
long term?
chemo?

Question 22

what should be checked with regards to Contraception /HRT

Answer 22

1) Missed pill

2) Interactions: antibiotics

Question 23

what should be checked with regards to methotrexate

Answer 23

1) potentially toxic
2) weekly
3) dose
4) strength of tablets
5) day
6) folic acid- to reduce the side-effects of methotrexate

Question 24

what should be checked with regards to Insulin

Answer 24

1) brand (and origin)
2) device
3) dose

Question 25

what drugs are used to treat Parkinson’s disease ?

Answer 25

1) Co-Beneldopa (Madopar)
2) Co-Careldopa (Sinemet)
- they need to get it on time

Question 26

what should be checked with regards to Bisphosphonates

Answer 26

1) daily or weekly
2) which day?
3) taking correctly?
4) calcium & vit D supplements?

Question 27

what should be checked with regards to inhalers?

Answer 27

1) drug
2) strength
3) device
4) dose & frequency

Question 28

what should be checked with regards to Drug misusers

Answer 28

1) methadone/Subutex
2) confirm doses with GP/DDU
3) inform prescriber/pharmacy

Question 29

what should be checked with regards to Mental Health

Answer 29

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.

Question 30

what should be checked with regards to Specialist services

Answer 30

1) Clinical trials
2) Chemotherapy
3) TB Meds
4) Gum clinic
- HIV meds

Question 31

list some drugs which commonly cause dispensing errors

Answer 31

1) Aminophylline & Amitriptyline
2) Beclometasone & Betamethasone
3) Promazine & Promethazine
4) Penicillamine & Penicillin

Question 32

with regards to the Continuity of treatment outline what the “five rights” are

Answer 32

1) right patient
2) right route
3) right drug
4) right dose
5) right time