1. Rachel Urban Pharmacist Researcher Bradford Institute of Health Research/ University of Bradford r.l.urban@brad.ac.uk

2. 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

3. Background

4. 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)

5. Patient enters hospital Drug History Taken, Chart written Validation of Drug History Medicines Reconciliation?

6. Patient enters Hospital Drug history taken Drug history verified Discharge written Discharge written Discharge Information Communicated Drug chart written Patient moves wards Patient counselled Patient Discharged Discharge Information processed Pharmacist Technician Pharmacist Technician Via A&E Direct to Ward Pre admissions Via A&E Direct to Ward Pre admissions Doctor Nurse Pharmacist Doctor Pharmacist Nurse Doctor Pharmacist Nurse Doctor Pharmacist ITC Home Care Home ITC Home Care Home POD /MDS Patient EHR Discharge info Community Pharmacy NH GP list POD /MDS Patient EHR Discharge info Community Pharmacy NH GP list GP DN CP SS Care Home GP DN CP SS Care Home CP, GP, Admin Staff Pharmacist, DN CP, GP, Admin Staff Pharmacist, DN

7. 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

8. 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

9. 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%

10. 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)

11. Primary Care Lack of evidence on Med Rec Robust repeat prescribing systems Ensure systems for processing information are robust

12. 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)

13. 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)

14. 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.

15. 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