Medicine Reconciliation

Policy

Medicine reconciliation is the process of accurately obtaining an accurate list of patient medicines and using this to ensure medicine use is safe and effective, without errors or discrepancies.

The prescriber is responsible for ensuring medicine reconciliation is completed whenever there has been a significant change in care, for example:

• hospital discharge
• transfer to residential care
• patient becomes classified as high-needs or complex.

Reconciling medication reduces errors that could impact patient safety and ensures repeat prescribing is accurate.

Following medicine reconciliation, a prescriber alters the patient's medications or writes a new prescription, if needed.

All staff involved in medicine reconciliation are appropriately trained.

Medicine reconciliation is audited as part of the practice's programme of internal audits.

Q79

We aim to undertake medicine reconciliation within 7 days of a significant transition in patient care.

Medicine reconciliation process

Refer to HSQC's Medicine Reconciliation Standard and their guidance tools and training materials

1. Collect and identify the patient's current list of medications
   • Gather information about all of the patient's medications (prescribed, over-the-counter, and complementary/herbal/rongoā).
     • Names of medicines (either trade or generic).
     • Dose, frequency, and method of administration.
     • Duration of treatment (short term or long term).
     • Reason for taking.
     • Any recent changes in the patient's treatment.
     • Whether medications are linked to a classification in Medtech.
   • Consult at least two sources, including the patient as the primary source if possible.
     • Primary source – Patient or their parent/caregiver.
     • Secondary source – GP, community pharmacist, community health team, rest home, specialist.
     • Tertiary source – Clinical notes, hospital medication chart, transfer letters, previous medicines reconciliation documentation.

     If the patient is coming for an appointment, request they bring all medication in the original bottles.

   • Ensure medications prescribed by other providers (e.g. specialist or pharmacist) are documented. These may be noted as prescribed externally.
   • Use HSQC, NZ Formulary, and the STOPP Criteria, as required.
   • Ensure all known allergies and adverse reactions are noted on the patient record.
   • Check if the patient has a shared care plan.
   • Speak to others involved in the patient's care, with their consent, e.g. family/whānau, other GPs, specialists, carers, pharmacist, and rest homes.
2. Compare the collected information against the prescribed information
   • Check all medications are clinically appropriate.
   • Check for potential drug interactions.
3. Identify and resolve discrepancies
   • Check there are no common errors.
     • Omission – such as inhalers or eye drops.
     • Substitution – both generic and name-brand medications are prescribed.
     • Alteration – dose, route, or frequency.
     • Addition – new prescriptions, especially if patient is unsure why they have been prescribed.
     • Duplication – more than one medication for the same condition.
   • Document in the patient record any alterations to dosage, medications stopped/started, errors, and patient difficulties such as non-adherence.
4. Record and communicate the outcomes
   • Adjust the patient's medication list in the PMS or write any new prescriptions needed.
   • Discuss any changes with the patient.
   • Offer advice and support if needed, and direct them to any relevant resources.
   • Consider referring the patient to other parties such as the pharmacist or whānau support.

Audit

Annually, at a minimum, the practice audits at least 10 patient records that show a discharge summary within the last 3 months.

1. Randomly select 10 patients who are most likely to have had a medication change, e.g. admitted acutely to hospital, elderly, or with complex health needs.
2. Complete the audit form and review the information collected.
3. Document any discrepancies or errors, along with the reasons for them.
4. Identify areas for learning or improvements.

Audit form: RNZCGP Medicine Reconciliation Sheet

Report any areas where learning is needed to the clinical governance group so opportunities for quality improvement can be identified.