Medicine Reconciliation

Policy

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

A registered healthcare practitioner is responsible for ensuring medicine reconciliation is completed whenever there has been a significant change in care, for example:

• hospital admission or 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, the healthcare practitioner alters the patient's medications or writes a new prescription, if needed.

All staff, including new staff and locums, involved in medicine reconciliation are appropriately inducted and trained, and can follow the practice's process.

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

Q92

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 Indici.
   • 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, consider requesting 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 care plan and speak to others involved in the patient's care, with their consent.

     For example, family/whānau, other GPs, specialists, carers, pharmacists, and rest homes.

2. Compare the collected information against the prescribed information
   • Identify and resolve discrepancies.
   • Check all medications are clinically appropriate.
   • Check for potential drug interactions.
   • 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.
3. Record and communicate the outcomes
   • Document the reconciliation and any actions taken in the patient record.

     You should record:

     • the date of the reconciliation
     • any alterations to dosage, medications stopped/started, errors
     • the outcome and reasons for any changes.
   • Adjust the patient's medication list in the PMS or write any new prescriptions needed.
   • Discuss any changes with the patient, and offer advice or support if needed. Direct them to any relevant resources.
   • Consider referring the patient to other parties such as the pharmacist or whānau support.
   • Ensure any care plans, relevant recalls, or repeat prescriptions are updated if required.

Audit

Q79

At least once a year the practice audits at least 10 patient records that show a discharge summary within the last 3 months.

1. Identify 10 patients who are most likely to have had a medication change, e.g. recently discharged from hospital, elderly, or with complex health needs.

   You may need to consider how many people carry out medicines reconciliation at the practice, and who does the audit:

   • If more than one person carries out medicines reconciliation, ideally a sample of reconciliations by each of those people is represented in the audit, as well as different patient groups.
   • A non-clinical person may be responsible for ensuring that the audit is carried out.

2. Complete the audit form and review the information collected.

   A clinical person, able to exercise judgement around the prescribing of medicines, will need to analyse the information collected.

3. Document any discrepancies or errors, along with the reasons for them.
4. Identify areas for learning or improvements.
5. Communicate results and any discrepancies to all staff involved in the process, and report them to the clinical governance group for discussion.

Audit form: RNZCGP Medicine Reconciliation Template

Clinical governance

The person coordinating the audit reports to the clinical governance group, where any areas for learning and improvement are discussed and documented.

A quality improvement initiative is carried out if required, followed by another audit.