1. Medicines Reconciliation A Whole System Approach Arlene Coulson Principal Clinical Pharmacist, Specialist Services Gordon Thomson Principal Clinical Pharmacist, Urgent Care, Medicine Every stage, every time for every patient!

2. Why, What, Where, When, Who and How? Why implement Medicines Reconciliation? What should it consist of? Where and when it should occur? Who should carry it out? How should it be implemented?

3. Why implement medicine reconciliation? Improving processes directly improves outcomes. REDUCE RISK, HARM AND VARIATION! Transitions from one healthcare setting to another increase risk of adverse drug events and contribute to avoidable hospital visits. (Dedhia et al. 2009; Fernandes 2009; Jack et al. 2009; Ong et al. 2006)

4. What should it consist of? Talk to Patient/ Family Patient Own Drugs/list Electronic medication records Standardised Medication Reconciliation Sources of Medicine Reconciliation Document in Medicines Reconciliation Documentation DischargeAdmission Patient’s medicine chart Electronic medication records Medicine Reconciliation Documentation Standardised Medication Reconciliation Document in Electronic Discharge Documentation Sources of Medicine Reconciliation

5. Medicines Reconciliation on admission

6. Electronic Discharge Documentation

7. GP SurgeryCommunity Pharmacy Admission to hospital Out patient Different levels of care Where and When should it occur? e e

8. HOME Medicines Reconciliation on admission to hospital Medicine Reconciliation on transfer of care settings Medicine Reconciliation at discharge HOME

9. Who Should Carry It Out? It is vital to have medical staff engagement right from the beginning!! Testing/Implementation; collaborative approach with Medical and pharmacy staff Any health professional can complete medicines reconciliation! Best to be part of the medical admission documentation. Medicine reconciliation is reviewed by clinical pharmacist

10. How should it be implemented? Breakdown each step in the process Identify the step with highest risk to fail - start here! Test on 1,3,5 patients (PDSA cycles) on admission Improve the process in this step so that its 95% reliable before moving to the other steps Prevent failure by standardising the process Measure the process regularly to determine reliability

11. Measurement for improvement % accuracy of medicines reconciliation in Acute Surgical Receiving Unit

12. Next steps for improvement Identify the gaps: Map out current processes for medicine reconciliation. Map out the ideal process for medicine reconciliation. Measure the quality of medicines reconciliation in all healthcare settings. Invest in areas where its been identified there is a gap. Reduce variation in practice across NHS Tayside Every stage, every time for every patient!