1. Common Traps with Sources for Medication Histories Thanks to the Pharmacy Department for their numerous suggestions August 2011

2. Objectives To be aware of some advantages and disadvantages of various BPMH sources To be able to avoid common BPMH traps where interventions are often subsequently made

3. General Practitioners/Specialists Referral letter with list often accompanies patient Administration officers can phone & fax request Useful for confirming details eg strengths  What the GP believes the patient takes  Often incomplete/not up-to-date  Not necessarily updated/deleted  Often no directions: ‘MDU’  Generally records of only 1 GP  Doesn’t include OTCs/CAMs/non-Rx/specialists  Often need to cross-reference with patient

4. GP List: Just 1 of 3 pages

5. Community Pharmacies Dispensing histories Administration Officers can phone & fax request Most Redland patients only use one pharmacy Will have information about dispensed items additional to a Webster pack Compliance: regularity of dispensing, items dispensed  May not be complete (other pharmacies, GP samples)  Rx and S4 (label required) items only  Need to go back in time eg digoxin comes in bottles of 200: may not have dispensed for 7 months

6. Community nurse & Patient lists A list from the ‘source’ (patient/carer) Generally kept up-to-date by patient/carer  May only consist of ‘prescribed medications’/those deemed ‘important’  Often inaccurate/incomplete/missing doses Ensure still up-to-date and fully complete Still need to ask other specific questions eg puffers, patches, eye drops, CAMs…

8. Previous Admission All QH admissions easily accessible via eLMS  …presuming that nothing has changed  Verbal changes to discharge medications not communicated to Pharmacy  no changes made to eLMS  Patient ceases items due to misunderstanding/dislike/cost/exhausted discharge supply etc  GP ceases items  Items added by patient/GP/specialist/OPD clinic  Prescribing/dispensing/administration errors  List may not have been complete on last admission  Up to 17% of items may be incorrect  Ensure still up-to-date and fully complete  The DMR is usually out-of-date the moment the patient leaves  MUST use as a BASELINE list to build upon

9. Charted amiodarone 200mg daily, but according to DMR from 5 days ago, should still be being loaded with 200mg bd for 5 more days Previous D/C (11/2010)Current admission (5/2011) Thyroxine 125mcg m Omeprazole 20mg m Aspirin 100mg mAsprin 100mg m Frusemide 60mg mmidFrusemide 80mg m ISMN SR 120mg mISMN SR 120mg n Coloxyl & Senna 2 bdColoxyl & Senna 2-4 n Paracetamol 1g tdsParacetamol 1g qid Cholecalciferol 25mcg m Temazepam 10mg prnTemazepam 10mg n Escitalopram 20mg mCitalopram 20mg n OxyContin 20mg bdOxyContin 5mg bd Metoprolol 25mg mCarvedilol 6.25mg bd Span K 600mg m Charted on admission

10. Residential care facility Should be an accurate representation of ALL medications NB Check for the RIGHT PATIENT!  ED pharmacist often notes the wrong chart has been sent  Directions can be ambiguous  Check for ‘cease date’ – order not necessarily crossed out  Chart may not be most recent orders  Check dates  RNs may give doses from a range eg ‘0-40mg’  Look at nurse administration section  More than 1 page of medication list  Check for eg ‘2 of 2’  May not correspond with community pharmacy supplies  Good practice to also request community pharmacy list  Community pharmacy details located on NH medication charts

11. Mismatch between NH Chart and Packed Medications

12. Look for STOP DATES! Looks as though still prescribed

14. The need for the second source Looks like ‘100 1 bd’ - Charted on admission Was originally ‘10mg bd’ Patient actually NO LONGER TAKING - (see cease date) Phone call to community pharmacy confirmed this

15. Patient’s Own Medications DO NOT send home with carer –Often need to refer back to them during admission Many details immediately evident Drug/strength/dose Compliance - # of tablets left vs dispensing dates vs expiry dates GP/community pharmacy information Taking other people’s medications/dispensing errors  Instructions may be out-of-date (refills of old Rx)  Patient may have brought in other people’s medication  CHECK NAME carefully & confirm with patient that still taking  Patient may not bring in all items eg if stored in the fridge  Contents may not match packaging eg halved tablets  MUST look inside the bottle

16. Colour-blind? ED pharmacist asked to review the medications for a warfarin pt with an INR>10 Warfarin started approx 10 days ago, advised to take 2mg daily –pt confirmed that he takes 2 brown Marevan tablets daily Vit K administered, pt to return next day for another INR Pharmacist asked pt to bring all his medications the next day for review The bottle containing 1mg tablets was still sealed and pt was actually taking 2 pink (5mg) tablets daily

17. Webster packs Can be a double-edged sword  Back of pack may not match contents  Patient may not take all of contents eg frusemide  Patient may take additional items eg warfarin, patches, puffers, injections  Some Webster’s wording groups multiple medications with the same strength together e.g. aspirin/allopurinol 100mg mane, instead of creating 2 separate entries for each drug

18. The danger of Webster packs Webster PackBPMH Quinapril 10mg m (NB back of pack states: 20mg) Quinapril 10mg m Frusemide 40mg mmid Paracetamol 1g qid Coloxyl & Senna 1 n Metformin 500mg bd Seretide 250/25 2 bd Lantus 14 units n Panadeine Ft prn WARFARIN

19. Implies daily dosing Actual dose = Tues & Fri only Front of pack often (BUT NOT ALWAYS) has ‘strange’ doses listed eg bisphosphonates/non-packed items Count the tablets Call the community pharmacy Can also need to check what’s not packed

20. Patients/carers Best when patient’s own medicines are present Ask open-ended questions Specifically ask about: (see MAP checklist) INJECTIONS: Insulin has been previously missed Patches/creams/eye drops/inhalers Once a week/month CAMs Non-Rx items…  Patients may not realise the importance of non-tablets  Some patients have filled new prescriptions but not actually started taking

21. Wording: what’s wrong with this picture? ‘What tablets do you take at home?’ ‘Avapro – 1 tablet in the morning, right?’ ‘Can you please list your medicines for me?’ ‘This is what I’m supposed to take…’ ‘What are you allergic to?’

22. Thank you! Questions