1. Intervention to minimise medication error on admission and discharge Medication Reconciliation Tamasine Grimes PhD, MPSI Research Pharmacist, AMNCH Associate Professor, Practice of Pharmacy, TCD Marie-Claire Jago-Byrne Chief Pharmacist Naas General Hospital

2. 89 year old female Presenting complaint –Melaena Medical history –Aortic stenosis, mitral regurgitation, hypothyroid, atrial fibrillation Diagnosis –Gastric cancer with liver mets Medication changes …

8. Medication reconciliation (Med Rec) “The process of obtaining and maintaining an accurate and detailed list of all prescribed and non-prescribed drugs a patient is taking, including dosage and frequency, through all healthcare encounters and comparing the physician’s admission, transfer, and/ or discharge orders to that list, recognising any discrepancies, and documenting any changes, thus resulting in a complete list of medications, accurately communicated”.

9. Fitzsimons M et al. International Journal of Pharmacy Practice (2011);19(6):408-16. Grimes T et al. British Journal of Clinical Pharmacology (2011);71(3):449-57. Galvin M et al. Int J Clin Pharm (2012, in press) Pre- admission medication list Availability Accuracy Admission Reconciliation Clinical pharmacy input common Unintentional unresolved discrepancies Inpatient episode Changes to long term medication Discharge reconciliation Non- reconciliation common Potential to cause harm and unplanned readmission

10. Governance Framework Local Drugs and Therapeutics Committees Building a Culture of Patient Safety –Dept of Health and Children, 2008 Draft National Standards for Safer Better Healthcare – Health Information Quality Authority, 2010 National Medication Safety Programme –Quality and Patient Safety Directorate, HSE, 2010 Acute Medicine Programme –Health Services Executive, 2011

11. Patient Safety Initiative Integrated Medicines Management (IMM) Inclusion of medication reconciliation Integrated, multidisciplinary working –Teamwork –Participation in ward rounds –Proactive rather than reactive input Comprehensive communication –Admission, during stay, discharge Scullin C et al. Journal of Evaluation in Clinical Practice (2007):13(5):781-8. Burnett K et al. Am J Health-Sys Pharm (2009):66:854-9.

12. Benefits & Outcomes Improved reconciliation at admission and discharge –Explaining changes to longstanding meds Development of relationship between: –Pharmacist and patient –Pharmacist and MDT, education, development Positive alignment of workflow –Systematic and timely approach –Patient’s journey through inpatient care –Proactive rather than reactive support in prescribing

13. Challenges & Supports Resources Hours of working Patient complexity –Multimorbidity –Polypharmacy Establishing PAML –Aging population Drugs and Therapeutics Committees Support of community colleagues Collaboration Practice based research ICT support The Meath Foundation The Adelaide Society

14. “Good communication: right meds on admission and discharge and rationalisation of appropriate prescribing” (Consultant) “Bit awkward having pharmacist working around you – not accustomed to it, would get used to it” (Reg) “Much better. Usually bleeped multiple times by multiple pharmacists. Much different if see person, more of a relationship.” (Intern) “Resource to hand on ward; if have query – instant resource and very rapid response” (Consultant) “Educational from both sides” (Intern) “Valued member of team, improved job satisfaction” (Pharmacist) “Now that the pharmacist is working as a member of our team we can make decisions about prescribing at an earlier stage and that saves us time” (Reg) “Especially on discharge, interns have so many things to do, medicines may be overlooked” (Intern) “The doctors now really understand the contribution I can make to patient care and my interventions are considered” (Pharmacist) “Having a pharmacist on the post-take ward round ensures timely answers to key questions in treatment and provides a multi-disciplinary service to the patient” (Consultant)