1. Medicines Reconciliation
Topic 8:
Medicines Reconciliation
Background, method and findings from the baseline audit
The Prescribing Observatory for Mental Health (POMH-UK) runs national audit-based quality improvement programmes open to all specialist mental health services in the UK. The aim is to help mental health services improve prescribing practice in discrete areas (‘Topics’).
This slide set contains the results of the baseline audit for Topic 8: medicines reconciliation.
POMH-UK is based at the Royal College of Psychiatrists Centre for Quality Improvement and does not receive any funding from the pharmaceutical industry.
Further information about POMH can be found on our website:

2. Medication errors can occur at the point a medicine is:
Background
Medication errors can occur at the point a medicine is:
prescribed (usually by a doctor)
dispensed (usually by a pharmacist)
administered (usually by a nurse)
Medication errors are:
a recognised common cause of avoidable morbidity and mortality
responsible for approximately 20% of clinical negligence claims in hospitalised patients (Audit Commission, 2001)
The point of transfer between care settings (in particular hospital admission) is a known period of high risk for prescribing errors (NICE, NPSA, 2007)
Errors can happen at the point a medicine is prescribed, dispensed or administered.
At each stage in the process the root cause may be a simple lapse in concentration, a problem with decision making, or a knowledge deficit.
Common types of prescribing errors include clerical errors made when transcribing medicine cards, and knowledge based errors which usually occur when prescribing unfamiliar medicines or medicines that have a high potential to interact in a clinically significant way.
Common types of dispensing errors include selecting a pack containing the wrong drug or dose, labelling with the wrong instructions, supplying the wrong quantity, or failing to identify a potentially serious drug interaction.
With respect to administration, the most common errors are selecting the wrong drug or dose, and giving the medicine by the wrong route or to the wrong patient.
Prescribing errors that are made at the point of transfer of care, particularly admission to hospital, are usually due to problems with medicines reconciliation.

3. Why this Topic was selected?
Background
Why this Topic was selected?
A technical patient safety solution that aims to reduce the prevalence of medication errors at the point of admission has been issued jointly by NICE and the NPSA. The safety solution focuses on the importance of medicines reconciliation.
The technical patient safety solution made it statutory that all Trusts had an approved policy for medicines reconciliation in place by December 2008.

4. Medicines Reconciliation
NICE/NPSA define medicines reconciliation as:
Collecting information on medication history
Checking this list against the current prescription chart
Ensuring any discrepancies are accounted for and actioned
Documenting any changes, omissions or discrepancies
“The aim of medicines reconciliation on hospital admission is to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission. Details to be recorded include the name of the medicine(s), dosage, frequency, and route of administration. Establishing these details may involve discussion with the patient and/or carers and the use of records from primary care. This does not include medicines review”
(NICE, NPSA, 2007).
Errors occur most commonly on transfer between care settings, and in particular at the time of hospital admission.
While at home, a patient may be taking a combination of medicines, some of which may have been prescribed by a GP, some by a hospital specialist and some of which may have been obtained without the need for a prescription.
In addition, few people adhere completely to prescribed medication regimens; partial adherence and non-adherence are common. It is therefore possible, and indeed likely that not all medicines that are prescribed are being taken in the way intended. At the point of admission to hospital, medicines that the patient has been taking at home can be missed and medicines that are prescribed but are not being taken can be re-instated. Both have the potential to cause harm.
For example, medicines such as insulin that are used to treat serious physical health problems can be missed, and drugs with a dose related potential to cause postural hypotension, such as clozapine, can be restarted at a dose to which tolerance has been lost.

5. A service user’s perspective
Background
A service user’s perspective
There is a culture of sharing medications, so people may be taking something that was prescribed, but not for them.
Service users may only tell their psychiatrist what they think they want to hear; that is about medicines related to that speciality. Medication for physical health problems may not be mentioned. Oral contraceptives may be missed.
Also, herbal preparations, or medicines such as
ibuprofen that can be bought without a prescription
may not to be mentioned.
Mental health service users may be reluctant to tell
a clinician that they have reduced or stopped taking
their prescribed medication because they think
they will be reprimanded.
There is a culture of people talking about what has worked for them and sometimes being generous enough to allow someone else a number of tablets so they can try it for themselves. So people may be taking something that was prescribed, but not for them.
When a service user is seeing a consultant for a physical problem as well as for a mental health problem, when asked about medication they may tell each consultant only what they think they want to hear, that is, the drugs to do with that specialty. This is because any medication for the other problem will be seen as not their concern (and it can seem as if the consultants see it like that too).
Also when someone is taking herbal preparations, especially if they have not been obtained from a Western medical source like a pharmacy or other shop (across-the-counter), they may not be mentioned when that person is talking about psychotropic medication they are taking. Ethnically derived herbal preparations, for example, will tend not to be mentioned.

6. Audit standard and relevant target
AUDIT STANDARD: Trust policy
The Trust has an approved policy for medicines reconciliation.
The policy clearly states who is responsible, in what timeframe and where medicines reconciliation information should be documented.
RELEVANT TARGET: Clinical practice
The aim of medicines reconciliation is that there is no unintentional discrepancy between medication prescribed prior to admission and medication prescribed at the point of admission.
The audit data allow benchmarking of the proportion of patients for whom medicines reconciliation was not possible because fewer than 2 sources of information about their current medication were checked.
The audit standard is drawn directly from the NICE/NPSA technical patient safety solution relating to medicines reconciliation.
The target is a proxy measure of whether medicines reconciliation is likely to have taken place. It is not possible within the constraints of audit methodology to know whether the information given by the patient, carer, GP or specialist is 100% accurate and has been interpreted and acted on in a way that ensures medicines reconciliation has been achieved.
We use the proxy measure of evidence that at least 2 sources have been used to obtain information about medication the patient was taking prior to admission; in such cases medicines reconciliation was possible (although we cannot be sure it happened). Where no sources or only one source was checked, medicines reconciliation cannot have been achieved.

7. Medicines reconciliation policy
Method: Part 1
Medicines reconciliation policy
A questionnaire to be completed by someone with a good knowledge of Trust-wide systems for managing medicines, e.g. Trust chief pharmacist, member of Trust’s Medicines Management Committee, was sent to each participating Trust
Questions addressed:
Whether the Trust had an approved or draft policy for medicines reconciliation, and within that policy:
Who had overall responsibility for ensuring medicines reconciliation was completed
Which other named staff had responsibilities
Whether the policy specified where to record details, which sources to use to obtain information, and the timeframe in which this should take place
Whether previous audits of medicines reconciliation had taken place
A copy of the questionnaire can be found in the Topic 8 Medicines Reconciliation baseline audit report. The POMH lead for your Trust will have a paper and electronic copy of this report.

8. Benchmarking the quality of medicines reconciliation
Method: Part 2
Benchmarking the quality of medicines reconciliation
Participating Trusts and clinical teams: acute adult, acute elderly and forensic wards (self-selected).
Audit inclusion criteria: patients recently admitted to ward and stayed for at least 7 days; minimum of 5 patients per ward advised.
Data collected for each patient:
Age, gender, ethnicity, diagnostic grouping, time of admission,
detainment under the Mental Health Act & ward type
Documented details of medicines prior to admission (prescribed
and non-prescribed), and adherence
Details of sources checked and discrepancies identified – from
discussion with the clinical team
Documentation of the reconciliation process
Time period of pharmacist and/or medicines management
technician involvement

9. Trust Policy; 45 Trusts entered data
Key findings: Part 1
Trust Policy; 45 Trusts entered data
AUDIT STANDARD
Trusts should have an approved policy for medicines
reconciliation; this was not met for 44% of Trusts
For those Trusts that had an approved medicines reconciliation
policy in place:
88% stated who was responsible for medicines reconciliation
80% stated the timeframe within which medicines reconciliation should take place
96% stated where to document the details of medicines reconciliation
Overall 22% of participating Trusts had an approved policy for
medicines reconciliation that stated who was responsible, in what
timeframe and where reconciliation should be documented.
The deadline set by the NPSA for having an approved policy in place was December Several months after this deadline, two Trusts in 5 had not completed this process.
Detail required by the NPSA was not included in some Trust policies.

10. Other findings: Part 1 - Trust Policy
Key findings: Part 1
Other findings: Part 1 - Trust Policy
56% of Trusts having an approved policy for medicines reconciliation is consistent with Department of Health Central Alerting System (CAS) data: 41% of mental health Trusts reported compliance with the NPSA requirements by the required deadline.
Doctors are most commonly identified in policies as having overall responsibility for medicines reconciliation, but the task is most likely to be undertaken by pharmacy staff.

11. Detained under Mental Health Act
Part 2; National findings
Forty-two Trusts submitted data for 1,790 patients from 375 clinical teams
Key demographic characteristics
Acute Adult
Acute Elderly
Forensic N=
1055
614
121
Gender
Male
550
(52%)
249
(41%)
102
(84%)
Ethnicity
White/White British
822
(78%)
551
(90%) 93
(77%)
Black/Black British 74
(7%) 14
(2%) 16
(13%)
Asian 71 4
(1%)
(3%)
Mixed or other 88
(8%) 45 8
Age
Mean age in years (SD) 42
(13.5) 77
(8.6) 37
(10.5)
Detained under Mental Health Act
Yes
462
(44%)
144
(23%)
120
(99%)
ICD-10
F00-F09 15
263
(43%) 2
F10-F19 57
(5%) 5
F20-29
464 75
(12%)
(64%)
F30-39
336
(32%)
190
(31%) 12
(10%)
Other
103 23
(4%) 11
(9%)
Diagnosis not yet reached 80 58
The majority of cases were admitted to either an acute adult or acute elderly ward. Age profiles and the proportion of patients detained under the Mental Health Act are largely in line with clinical expectations. The majority of the sample as a whole had a diagnosis of either schizophrenia spectrum disorder (F20-29) or affective disorder (F30-39), with the breakdown of diagnoses across clinical settings differing in line with clinical expectations.

12. National findings
Details about the medications prescribed prior to admission documented in the clinical notes (n=1,790)
This chart shows similar levels of documentation of the names and doses of medication in acute adult & acute elderly settings. An adequate level of detail is documented in approximately 2/3 in the adult & elderly services, and 4/5 in forensic services. It might be speculated that the increased level of documentation seen in forensic settings reflects a higher proportion of planned admissions.
Fewer than 10% of patients were not prescribed any medication prior to admission.

13. National findings
Documentation of adherence to prescribed medication in adult (n=964), elderly (n=592) and forensic (n=112) services
Documentation relating to adherence to medication regimens was more common in acute adult and forensic wards than elderly wards, which may reflect the assumption of health professionals that elderly patients are more likely to take their medication as prescribed. Another contributing factor could be that carers or residential home staff are available to confirm that medication has been taken.
In the acute adult setting, the proportion of patients documented as having poor adherence is in line with the published literature on the prevalence of poor adherence in mental health (Cramer & Rosenheck 1998, Lacro et al 2002). Full details for these references can be found in the baseline audit report.

14. Sources of information checked
Adult wards Elderly wards
Forensic wards
These three Figures show the sources checked by clinical teams within 24 hours, 3 days and 7 days of admission in each setting.
These 3 Figures suggest that most sources that are going to be checked, are checked within the first 24 hours of admission. With the exception of contacting GPs, there is little further evidence of reconciliation in the subsequent six days.
Clinical teams were given the option of reporting any other sources they used to check medicines. Other sources frequently used by staff included consulting other hospitals or departments, old notes from a previous admission to the ward, and asking a patient’s friends and family.

15. Discrepancies identified from each source
Adult wards Elderly wards
200
400
600
800
1000
Residential or care home
Carer asked
Other source used
Medication examined
GP consulted
Community Mental
Health Record
Patient asked
N adult patients (N=1055)
100
200
300
400
500
600
Residential or care
home
Other source used
Carer asked
Community Mental
Health Record
Patient asked
Medication examined
GP consulted
N elderly patients (N=614)
Discrepancy
identified within
24 hours of
admission
3 days
7 days No
discrepancies
identified
Forensic wards
These three Figures show the discrepancies identified by each sources checked by clinical teams within 24 hours, 3 days and 7 days of admission in each setting.
In these 3 Figures, for each source the total bar length represents the number of patients for whom the source was consulted (as a non-primary source). These graphs exclude consultation with primary sources, as by definition a discrepancy cannot be identified from the first source checked. The darker parts of the graphs (green, blue and purple) show the number of contacts in which a discrepancy was identified. The scale given is absolute patient numbers.
Overall, the GP was the source most likely to identify an unintentional discrepancy with the prescribed medication. Asking the patient and examining the medication brought in also provided worthwhile information. In addition, for those patients transferred from prison/remand or a residential/care home, those sources regularly identified discrepancies.

16. Discrepancies identified by:
Source
% of enquiries yielding a discrepancy
Adult
patients
Elderly
Forensic
Patient 15 11 6
Medicine 16 9
Carer 8 GP 34 28 13
CMHR
Care home 23
Prison/remand - 24
Non-forensic
Other 12 21
One or more discrepancies were identified in 21% (374/1,790) patients.
 Yield of discrepancies: the proportion of applicable enquiries for each sources which identified a discrepancy.
 Proportion of discrepancies identified during medicines reconciliation by particular clinical team members.
The top table summarises data from the graphs on the previous slide, and indicates the proportion of discrepancies identified from each source.
The bottom table: According to local Trust Medicines Reconciliation policies, overall responsibility for medicines reconciliation most commonly lies with a doctor, and partial responsibility most commonly with a pharmacist or pharmacy technician. The data in the Table above suggest that in practice pharmacy staff take on the associated tasks.
Discrepancies identified by:
Adult
N (%)
Elderly
Forensic
Pharmacist
168 (49%)
80 (43%)
16 (73%)
Doctor
83 (24%)
63 (34%)
3 (4%)
Pharmacy/medicines management technician
43 (13%)
28 (15%)
3 (14%)
Other (including patient, nurse, ward clerk, or other member of team)
47 (14%)
17 (9%)
0 (0%)

17. Clinical significance of the discrepancies identified
A small number of the discrepancies identified were clearly clinically significant
Omission of low molecular weight heparin
Wrongly transcribed lithium dose
Some had the potential to be clinically significant in the short/medium term
Omission of inhalers for asthma/COPD
Omission of oral antidiabetic medicines
The clinical significance of the majority of discrepancies was difficult to determine
Changes in the time of administration of psychotropic medicines
Missing medicines for minor ailments (creams etc)
If your Trust opted to collect qualitative data relating to discrepancies identified during the process of medicines reconciliation, these have been returned to your POMH lead on a EXCEL file for further local analysis.

18. Trust level
Details about the medications prescribed prior to admission documented in the clinical notes (n=1,790)
The Trust with the highest proportion of patients for whom both the name and dosage of medications prescribed prior to admission documented in the clinical notes is on the left hand side of the Figure and the Trust with the lowest proportion on the right. The proportions in the total national sample (TNS) are shown on the far right of the Figure.

19. Trust level
Documentation of adherence to prescribed medication in adult, elderly and forensic services
The majority of the TNS was drawn from acute adult settings, and in this group the documented level of poor adherence is in line with the published literature.
The Trust with the highest proportion of documentation regarding adherence in the clinical notes is on the left hand side of the Figure and the Trust with the lowest proportion on the right. The proportions in the total national sample are shown on the far right of the Figure.

20. Trust level: sources of information checked
Trust level: Subgroups of patients according to the number of sources checked within 7 days of admission.
For 519/1,790 patients (29%) in the red or red striped sections (0 or 1 sources) reconciliation could not have taken place.
For the graph above, the Trust with the highest proportion of patients for whom 2 or more sources were checked is on the left hand side of the Figure and the Trust with the lowest proportion on the right. The proportions in the total national sample are shown on the far right of the Figure. For patients in the red or red striped sections (0 or 1 sources) reconciliation could not have taken place.

21. Discrepancies identified
The proportion of patients in each Trust for whom two or more sources were checked (i.e. medicines reconciliation was possible), and the proportion for whom one or more discrepancies were identified (n=1,271).
The Trust with the highest proportion of patients for whom two or more sources were checked is on the left hand side of the Figure and the Trust with the lowest proportion on the right. The proportions in the total national sample are shown on the far right of the Figure.
Based on the sample of patients for whom two or more sources were checked (n=1,271), it is likely that at least one discrepancy is identified in about a quarter of patients (n=319), although in most cases these are unlikely to be clinically significant, see section Nevertheless, these findings suggest that if all participating Trusts had checked 2 or more sources in all of their patients (n=1,790), at least one discrepancy would have been identified in an additional 130 patients.

22. RELEVANT TARGET Key findings: Part 2 - Clinical Practice
For 29% of patients in the total national sample, fewer that 2 sources of information about currently prescribed medication were checked (range across participating Trusts from 0% to 80%). Thus, medicines reconciliation would not have been possible in these cases.
During the process of medicines reconciliation, discrepancies were identified in 25% of the total national sample for whom two or more sources of information had been checked.
Of the specific discrepancies reported, only a small proportion were clearly clinically significant.

23. Team level findings

24. Documented details about medicines prescribed prior to admission
The team with the highest proportion of patients for whom both the name and dosage of medications prescribed prior to admission documented in the clinical notes is on the left hand side of the Figure and the team with the lowest proportion on the right. The proportions in the Trust, and the total national sample are shown on the far right of the Figure.

25. Documented details regarding adherence
The team with the highest proportion of documentation regarding adherence in the clinical notes is on the left hand side of the Figure and the team with the lowest proportion on the right. The proportions in the total national sample are shown on the far right of the Figure.

26. Number of sources used in reconciliation
The team with the highest proportion of patients in whom 2 or more sources were checked is on the left hand side of the Figure and the team with the lowest proportion on the right. The proportions in the total national sample are shown on the far right of the Figure. For patients in the red or red striped sections (0 or 1 sources) reconciliation could not have taken place, as by definition there must be two or more sources checked.

27. Team level findings
The proportion of patients for whom two or more sources were checked, and the proportion for whom one or more discrepancies were identified
The team with the highest proportion of patients for whom two or more sources were checked is on the left hand side of the Figure and the team with the lowest proportion on the right. The proportions in the total national sample are shown on the far right of the Figure.

28. What happens next?
Your Trust’s Local Project Team Lead (LPTL) has a copy of the full report, please ask them for a copy to see these findings in more detail.
POMH is developing a patient-led intervention that highlights the importance of telling the doctor about all medicines that are currently being taken.
A national conference addressing medicines reconciliation and the quality of lithium monitoring will be held on 1st December 2009, at the RSM. Put this date in your diary. Further details will be follow soon.
A re-audit will be conducted in September 2010.
If you have any questions, please ask your LPTL or POMH