1. “Medicines Reconciliation” Audit
Dr Gareth Watts
ST4 Palliative Medicine

2. Contents Rationale behind audit Introduction Methods
Results 1st and 2nd data collection
Conclusions and recommendations

3. Rationale Patient admitted for symptom control.
MST told to be taken home with relatives.
Patient unaware of regular medication.
MST omitted for 5/7.
How did this occur?

4. Introduction Medicines Reconciliation:
Process followed to ensure medicines prescribed correspond to those taken prior to admission.

5. Introduction Marie Curie Medicines Management Policy
Information confirmed by at least two sources:
Patient/carer/own drugs
GP surgery
Hospital letter e.g discharge/outpatient

6. Introduction
Essence of this audit:

7. Introduction
NICE/NPSA 2007:

8. Standards
Standard 1: The source of the drug history is documented in 100% of admissions.
Standard 2: Evidence of confirmation of this drug list within 24 hours of admission in 95% of admissions.

9. Methods – Collection 1 40 random case notes:
20 prospectively obtained
20 retrospectively obtained
Admissions Dec ‘11 - Feb ’12
Case note analysis

10. Methods Evidence of source of drug history?
Clerking list of medications noted
Evidence of source of confirmation?
If not, GP asked for a prescription copy.
List of drugs on confirmation noted
Comparisons made.

11. Nutritional Supplements
Methods
Omissions:
Dressings
Nutritional Supplements
Equipment e.g needles

12. Results: Patient Demographics
Average Age: 69 years ( years)
55% male; 45% female
Diagnosis:

13. Results: Clerking Details
OOH Admissions = 17.5% (n = 9)
Admitted:
55% from home (n = 22)
45% from hospital (n = 18)

14. Results: Drug History Source
Source of drug history was not documented in any case note examined.
Standard 1 not met.

15. Results: Reconciliation
Total admissions with a source of reconciliation at time of clerking or within 24 hours = 47.5%
Standard 2 not met.
83%
18%

16. Results: Reconciliation
Source of reconciliation:

17. Results: Drug Documentation
Total discrepancies between clerking proforma and external source:
Omissions/Additions = 82.5% (n = 33)
Dose discrepancies = 55% (n = 22)
Total discrepancies = 87% (n = 35)

18. Results: Drug Documentation
Opioid discrepancies:
2 omissions (5% of total; 6% of those on an opioid)
11 dose discrepancies (27.5% of total; 33% of those on an opioid)

19. Results: Drug Documentation
Of those with a source of reconciliation at time of clerking (n = 19):
Omissions/Additions = 63% (n = 12)
Dose discrepancies = 47% (n = 9)
Total discrepancies = 73.6% (n = 14)
BUT – no opioid discrepancies

20. Conclusions Documentation of source of drug history is poor.
High rate of discrepancy between drugs documented in drug history and source of confirmation.
BUT - this does not necessarily correlate to what appears on the drug chart.

21. Conclusions
A source of confirmation was available in 47% with 24 hours:
Rate of discrepancy was lower but still high...
BUT - higher incidence of 100% concordance and no opioid discrepancies.

22. Recommendations Raise importance of accurate drug history.
Proforma redesign.
Increased role of admin team.

23. Second Data Collection
36 admissions
All prospective data collection.
July 2012 – September 2012

24. Results: Patient Demographics
1st Data Collection
2nd Data Collection
Average Age
69yrs (43 – 91)
66yrs (28 – 85)
Male: Female
55%:45%
58%:42%

25. Results: Admission Details
OOH admissions = 16% (n= 6)
Admitted:
72% from home (n = 26)
28% from hospital (n = 10)

26. Results: Drug History Source
After intervention:
Source of drug history only documented in 38% (n=14).
Standard 1 not met.

27. Results: Reconciliation
Total admissions with a source of reconciliation within 24 hours = 58.3%
Standard 2 not met.
100%
21%

28. Results: Drug Documentation
Total discrepancies between clerking proforma and external source:
Omissions/Additions = 25% (n = 9)
Dose discrepancies = 30.5% (n = 11)
Total discrepancies = 33% (n = 12)

29. Results: Drug Documentation
Opioid discrepancies:
0 omissions.
3 dose discrepancies (8% of total; 9% of those on an opioid)

30. Results: Drug Documentation
Of those with a source of reconciliation at time of clerking (n = 21):
No opioid omissions or dose discrepancies.
All within this group had complete correlation.

31. Conclusions Interventions had not resulted in standards being met.
But some improvements in quality of drug history.

32. Discussion
Modest improvement in documentation of source – is this important?
Some improvement in source of confirmation within 24 hours.
Why was this not better?

33. Discussion Attitude to drug history taking from juniors?
Who’s job is it to perform medicines reconciliation?
What appears on the drug chart?
Unfortunate timing…….

34. Discussion
3 admissions with complete concordance without record of a source on admission.
? because of access to CanISC.
Rate of discrepancies in second data collection was lower.

36. Any Questions?