1. Continuity of Medication Management Medication Reconciliation: Beyond Admission Hospital Presenter Month YYYY

2. Continuity is an Issue in Health Care 10-67% of medication histories contain at least one error 1 Incomplete medication histories at the time of admission have been cited as the cause of at least 27% of prescribing errors in hospital 2 The most common error is the omission of a regularly used medicine 3 Around half of the medication errors that happen in hospital occur on admission or discharge 4 30% of these errors have the potential to cause harm 3,5

3. NSW Examples - Medication Errors Aspirin and clopidogrel ceased in ICU and not recommenced when patient transferred to ward Patient suffered sudden cardiac arrest resulting in death May have contributed to patient’s death Patient prescribed ramipril 1.25mg daily, medication chart was rewritten as ramipril 12.5mg daily Patient suffered pre- syncopal episode, was transferred to HDU and required noradrenaline Caused temporary harm and required intervention Patient initiated on new cardiac medication, discharged with no summary or medicine Patient became acutely unwell and was re-admitted Caused temporary harm and required intervention

4. Medication Reconciliation A process to reduce adverse medication events by: -Ensuring patients receive all intended medicines -Mitigating common errors of transcription, omission, commission and duplication -Ensuring accurate, current and comprehensive medication information follows patients on transfer and discharge

5. Complete Step 3 and Step 4 at transfers between: -ICU to ward -ED to ward -Ward to ward -Hospital to hospital -Hospital to home or aged care facility and -When re-writing or reviewing medication charts

6. NSW Medication Management Plan (MMP) Facilitates Medication Reconciliation at Transfers Area to record medicines taken prior to presentation Contains a list of the patient’s pre- admission medications for comparison. It is available at the point of care. Know where to find the most accurate list of your patient’s pre-admission medications, commonly referred to as the Best Possible Medication History (BPMH)

7. Re-Writing or Reviewing Medication Charts Consider re-writing an opportunity to review a patient’s medications: -Pre-admission medications with -Prescribed medications Consider: -Medications to be re-started -Medications no longer required -Medications to be adjusted or commenced Check: -New chart with previous chart -Any changes made have been documented

8. Change in Clinical Setting / Ward Compare: -Pre-admission medications with -Prescribed medications Consider: -Medications to be re-started -Medications no longer required -Medications to be adjusted or commenced Communicate: -Medications that are to be continued -Any changes that have been made -Any ongoing plan ED ICU Ward 1 Ward 2

9. Hospital to Hospital Referring hospital to: -Communicate -Medications that are to be continued -Any changes that have been made -Any ongoing plan -Provide a copy of -Pre-admission medications (to facilitate identification of changes) -Prescribed medications (as a reference for the new treating team)

10. Hospital to Hospital Accepting hospital to: -Compare -Medications that are to be continued with previously prescribed medications and pre-admission medications -Identify and clarify -Any changes that have been made -Any ongoing plan

11. Hospital to Home or Aged Care Facility MMP Medication Chart Compare: -Pre-admission medications with -Prescribed medications Consider: -Pre-admission medications to be re- started -Prescribed medications no longer required -Medications to be adjusted or commenced

12. Hospital to Home or Aged Care Facility Communicate to the next care provider and patient: -Medications that are to be continued -Any changes that have been made -Any ongoing plan Example of a medication list for the patient

13. A Final Check Ensure the same medicines information is provided on the: -Discharge summary -Discharge order/prescription -Discharge medicine labels -Patient medication list Ensure the patient understands the changes that have been made

14. Key Points Medication errors and patient harm can be reduced by reconciling medicines when re-writing medication charts and at transfers between: -ICU and ward -ED to ward -Ward to ward -Hospital to hospital -Hospital to home or aged care facility Providing accurate information at transfers/discharge results in safer ongoing care

15. References 1.Lee JY, Leblanc K, Fernandes OA, et al. Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry. Ann Pharmacother. 2010;44:1887-1895. 2.Santell JP, Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32:225-229. 3.Elliott RA, Tran T, Taylor SE, et al. Impact of a pharmacist-prepared interim residential care administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study). BMJ Open 2012; 2:e000918. 4.Stowasser DA, Collins DM, Stowasser M. A randomised controlled trial of medication liaison services – patient outcomes. J Pharm Pract Res 2002; 32:133-40.