Safe Prescribing: History and Reconciliation Flashcards
1
Q
What is medicines reconciliation
A
- This is a process designed to ensure that all medication a patient is currently taking is correctly documented on admission and at each transfer of care (e.g. admission and discharge to and from hospital and other care settings)
2
Q
what are the three stages of medicine reconciliation
A
- Admission – usually don’t bring there medication with them so need to look at a care record
- Post admission verification (by pharmacy team) – pharmacy team will undertake a level 2 medicine reconciliation – look at two to three sources about the patient medication and see what is correct for that patient
- Discharge – restart medication that needs to be restarted when patient goes back out into primary care
3
Q
when do the large majority of medication errors happen
A
- Large reduction of admission and discharge and at follow up there is a small amount of errors
4
Q
what are the problems that come about when prescribing in a hospital
A
- In a hospital have patients that are going through multiple wards and are often changing drug charts as their changing boards
- Could be errors when the drug chart is rewritten
- Change between hospital and this can cause the information to change between hospitals
- Critical care admissions – patients stop their normal medication and when they come out of critical care they restart that medication which can lead to error
- Chain of misinterpretation – dosage and medication
5
Q
what does an accurate drug history allow
A
- Accurate drug history allows the team to prescribe the patient usual medication clearly and accurately on their drug chart,
- allows them to continue taking their medication without delays or omissions,
- identify any medication related issues that contribute to the patient admissions
- identify any other medication that may be needed
6
Q
What are the history taking steps in drug history
A
- Collecting information – on the drug history using the most recent and accurate sources of information
- Checking or verifying – list against the initial inpatient prescription, ensuring any discrepancies are accounted for and appropriately followed up – if changing the prescription document why you have done that
- Communicating – the drug history together with action taken on any changes, omissions and discrepancies through appropriate documentation
7
Q
What are the sources of information for drug history
A
- Patient
- Patients own drugs
- Summary care records
- Carer or nursing home
- GP surgery – phone call, medication record, referral letters
- Previous eTTA (discharge summary)
- Community pharmacy
- Prescription from another hospital
- Repeat prescription list
8
Q
what are the advantages and disadvantages from taking drug history from the patient
A
Advantages of taking history from the patient
- Important source as the patient will tell you exactly how they take their medicines
- Always try to establish how exactly a patient takes their medicines as this could be different from the formal records
Disadvantages from taking history from the patient
- Confused
- Unable to communicate
- Speak English
9
Q
what are the advantages and disadvantages of patients bringing in there own drugs
A
Advantages
- Encourage patient to bring in their own medication from home
- Discuss each medicine with the patient to establish how long they have been taking it and how frequently
- Do not assume that the dispensing label accurately reflects the patient usage
- Check the date of the dispensing since some may bring all their medication into hospital including those that are stopped
Disadvantages
- Patient may leave PODs at home or they maybe old or illegible
10
Q
name a compliance aid that can be used for administering drugs
A
dosette boxes
11
Q
Who can dosette boxes be filled by
A
- These may be filled by the community pharmacist, district nurses, relatives or the patient themselves
- If dispensed by a community pharmacist the device should be checked for dispensing labels which provide pharmacy contact details
- Date of dispensing
12
Q
What should you check for in the dosette boxes
A
- Check for when required medicines and medicines that may not be suitable for compliance aids such as inhalers, eyedrops, once weekly tablet
13
Q
How are relative and carers helpful
A
- Patients may have relatives’ friends or carers who help with their medicines
- Common with elderly patients or with patients where English is not there first language
- Can be helpful in establishing an accurate drug history and can also give an insight into how medicines are managed at home but may not have this insight
- Important to maintain confidentiality e.g. patient who is HIV positive
14
Q
what should always be checked in a repeat prescription
A
- Some patients keep copies of all their repeat prescriptions
- May include medicines that have been stopped
- Date of last issues should always be checked and each item confirmed with the patient
- If there is any doubt the GP surgery should be contacted
15
Q
what is the benefits from getting a drug history from the GP surgery
A
- An emailed (faxed) list is preferable
- Be aware of acute medicines, repeat medicines and past medicines on receptionists screen
- Always check when the item was last issued and the quantity issued
- Specific questioning may be needed for different formulations, inhalers, insulin devices or medicines which are brand specific (aminophylline, theophylline).
- Some medications are hospital only and do not appear on the usual repeat list (i.e warfarin, methotrexate, cloazapine)
16
Q
what is the downside to GP referral letters for a drug history
A
- Not always reliable
- Often written by the on-call doctor and may be illegible or incomplete
- May be necessary to double check the drug history with the patient, relative or GP surgery
17
Q
why are previous discharge summaries not necessarily a good use for drug history
A
- Check whether any changes have been made by the GP since the patient’s previous discharge from hospital
- If the patient has been home for more than two weeks it is likely that they may have visited their GP and changes made
- Discharge summaries that are more than one month old should not be used as a sole source of a drug history
18
Q
describe how residential and nursing homes can be used for drug history and the downside and upside of them
A
- Medication administration record sheets (MAR sheets)
useful and accurate source for a drug history - Usually sent in with the patient
- Handwritten lists from homes should be used with care as they often have transcription errors
19
Q
What are summary care records
A
- SCRs are an electronic record containing key information from the patients GP practise
20
Q
what is the downside of summary care records
A
- Optional – patient have received information through the post and can opt out of having an SCR via their GP practise
- Only accessible with permission from the patient except for exceptional circumstances where the patient is unable to give permission e.g. unconscious or confused
