Analysis
A primary care initiative to
support medicines reconciliation
Ian Nicholls MRPharmS and Michael Wilcock MRPharmS
Figure 1. Extract from a medication history faxed from the patient’s GP practice
edication error is an impor-
M tant cause of avoidable harm
suffered by patients, and it is recog-
nised that errors occur most com-
monly at the interfaces of care,
especially at admission.
Numerous studies have
described the extent and nature of
the discrepancies between the med-
icines patients were taking prior to
admission and their prescribed
medication on admission. 1,2
Critically, if the medication history
is incomplete, essential medicines
may be omitted both during the
inpatient episode and when the
patient is discharged back to the
community.
Many potential causes for these
errors have been noted. These
include those relating to the patient
or carer (lack of knowledge of the
medicines used or an inability to
recall medicines); those relating to
failures in the transfer of informa-
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tion from the GP to hospital in a
timely way; and those caused by mis-
takes made by staff admitting
patients.
Of note, the information pro-
vided by the GP practice about a
patient’s condition (and any med-
ication history) may reflect the sort
of information the GP feels that
they should provide rather than
information tailored to the needs
of those wishing to compile an
accurate medication history.
Ideally a minimum of two
sources of medication information
are required to give a reliable med-
ication history, though there may
be occasions when one source can
be used to confirm a history with a
patient who has some understand-
ing of their medications.
It is important to recognise the
limitations attached to the various
sources of medication history (see
Table 1).
The authors describe a new
approach they have devel-
oped to provide a reliable
medical history on admission
from GP practice records.
Medicines reconciliation
Various national reports 3,4 have
indicated the need to identify effec-
tive interventions that can reduce
medication error at admission, cul-
minating in recent guidance 5
requiring healthcare organisations
that admit adult inpatients to put
policies in place for medicines rec-
onciliation on admission.
Medicines reconciliation has
been defined 6 as the process of
obtaining an up-to-date and accu-
rate medication list that has been
compared to the most recently avail-
able information and has docu-
mented any discrepancies, changes,
deletions or additions resulting in
‘a complete list of medications,
accurately communicated’.
A range of approaches to improv-
ing the process of medicines recon-
ciliation have been described,7
though specific challenges are asso-
ciated with the different types of
Prescriber January 2010 35
Analysis
interventions, and there are some
differences in the cost-effectiveness
of the various interventions.8 For
instance, information technology
initiatives9 may not be feasible in all
areas, and acute trusts may not have
the resource to deliver a full phar-
macy-led medication assessment
service.
In addition, primary care may
not be aware of, or may not be act-
ing on, the need to provide a mini-
mum dataset on medication
information for patients admitted
to hospital.10
A new approach
Electronic care records are used in
all GP practices and contain infor-
mation about the patient that could
potentially improve the safety and
efficiency of medicines reconcilia-
tion if this information was available
at admission.
Working with various stake-
holders we set out to develop and
roll out across the PCT a system that
would make the retrieval of this
information smooth and simple
while increasing the quality of the
information provided.
Method
In conjunction with hospital phar-
macists actually undertaking med-
icines reconciliation and utilising
national guidance,5,11 we drew up
a list of essential pieces of infor-
mation that corresponded closely
to the nationally recommended
minimum dataset, but also con-
tained additional information
requirements that, if provided, may
benefit the admissions process (see
Table 2).
Comments on the content of
this dataset were sought from a
local health community-wide mul-
tidisciplinary group set up to imple-
ment the NICE/NPSA guidance,
and also from a sample of hospitals
doctors involved in the admissions
process. This consultation sought
36 Prescriber January 2010
Source Error risk
Patient’s own drugs discontinued medicines may be brought in and
considered current
patient may not bring in all current medications
if a patient brings in blister-packed medication it
may be erroneously assumed that they do not
use any other medicines (eg inhalers, liquids,
creams, eye drops, etc)
Repeat prescription slip out of date or other people’s (eg spouse’s)
repeat prescriptions may be presented
dosage instructions may not be included on
repeat slips
medicines that have been discontinued and
acute medicines may remain on the repeat slip,
not having been delisted from the practice
computer system
Handwritten GP letter often incomplete as based on limited access to
information
GP computer system may contain truncated dose instructions printed
print-out as GP practice-defined short codes that cannot
be interpreted outside of the practice
may contain truncated information on the
strength of the medicine where the approved
name is long
may list all medicines on the computer system
including those that should have been delisted
and that the patient is not currently using
often contain a lot of extraneous information that
is not useful for the purpose of taking a
medication history
Phone call to the patient’s may involver speaking to medically untrained
GP practice member of staff, leading to errors interpreting
the data on the computer system
time consuming both for practice and hospital staff
Table 1. Risks associated with different medication history sources
to ensure that the dataset captured ing a document that, once loaded
the patient’s relevant medical his- onto the system, would extract and
tory, hence avoiding the need to populate the details listed in Table
seek additional information from 2 into a template document. It was
the GP practice once patients were important that such a template
admitted. avoided some of the problems asso-
In Cornwall and Isles of Scilly ciated with existing reports such as
PCT about 70 per cent of the 71 GP the inclusion of truncated infor-
practices use one supplier for their mation.
GP computer system (Microtest Pilot testing of the template in
Ltd) and this supplier was one practice identified that the
approached for advice on develop- process of extracting the necessary
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information and faxing to a dedi-
cated safe-haven fax in the hospital
pharmacy took just a matter of
minutes.
The various ways that hospital
pharmacies might request these
reports were discussed with the GP
practice pilot sites. E-mail was dis-
counted as it required an ongoing
action for surgery staff to check e-
mails and it was thought there
might be difficulties with this.
Telephone calls from the hospi-
tal pharmacy attract their own con-
straints of contacting practices
during busy periods, and the recep-
tionist answering the telephone, as
well as being busy, is often not in a
position to generate the report.
The method settled on, and the
one most practices preferred, was
requesting reports by fax.
Wider roll-out to other prac-
tices was to be facilitated by incor-
porating an appropriate action
linked to medicines reconciliation
in the annual PCT Prescribing
Quality Scheme, which suggests
that practices use this document as
the primary source of medicines
information when admitting
patients in normal working hours.
Results and discussion
There have been a number of
challenges in implementing this
initiative across all practices.
Various routes of communication
have been employed to raise
awareness about this initiative, and
so far the most effective method
to get the software loaded onto
the system has been to use PCT
prescribing team staff to carry out
the installation and then to
demonstrate it to the practice, ide-
ally to as many key members of
practice staff as possible.
Those practices using computer
systems other than Microtest have
been helped in developing their
own template suitable for their sys-
tem. In most cases, practice systems
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Analysis
had existing templates requiring mation from the patient’s GP as
only slight modifications to meet soon as the normal weekday phar-
the required dataset. macy service is operating.
Currently approximately 70 per Difficulties have arisen where
cent of the practices are providing reports have been requested and
the template on request. The list of the practice has not responded to
which practices offer this service, the request or has sent in the wrong
along with practice details (tele- sort of, and generally less useful,
phone and fax numbers), is commu- report. These difficulties were
nicated to hospital pharmacy staff. resolved by contacting the practice
Feedback from hospital phar- and ensuring that those staff pro-
macists has been that they find this ducing the reports understood
ser vice ver y useful as it provides what exactly was required.
easy access to high-quality medi- Improvements to the system that
cines history for patients unable to have been suggested include finding
provide this themselves. This is ways of transmitting the information
especially the case for patients electronically, thus preventing the
admitted out of hours, when the need to print the document at the
pharmacist can request the infor- practice and hospital ends.
Essential
Full name and address of the GP practice including fax and telephone numbers
Date the report was printed
Full patient name including middle name
Full address including postcode
Home telephone number
Date of birth
NHS number
Registered GP
The patient’s last recorded weight and the date it was recorded
Regular medicines that the patient is prescribed including ALL of the following
- full drug name including strength and form (not truncated)
- full directions (not truncated or short codes)
- the quantity prescribed
- the date a prescription was last issued
- (optional) number of times this item issued
Acute medicines that remain on the patient’s drug screen given within the last
56 days (to include ALL of the items described)
All patient allergies recorded in the allergy section of the computer program
including ALL of the following:
- the drug or substance that caused the allergy
- the date the allergy was added to the computer
- any free text information added that gives further information about the
nature of the reaction
The last 1 month’s consultation notes
Important/high priority READ codes
Additional
Last eGFR reading and the date on which it was recorded
CKD registration READ codes and the date added
Whether the patient uses a compliance aid at home
Table 2 Details extracted from GP computer system
Prescriber January 2010 37
Analysis
The use of such a template is not
a totally novel idea.12 There is some
limited evidence describing an IT-
based information transfer initiative
that involved the use of a template
that could be faxed by the GP prac-
tice to the admitting ward.13 This
new pattern of care reduced the
number of incorrect medication
sheets by 69 per cent, with errors
falling from 55 to 17 per 100 patients.
Hence the limitations of this
approach include the lack of a sup-
porting robust evidence base, and
the fact that it cannot be applied to
out-of-hours admissions. In addi-
tion there are likely to be occasions
when the information contained on
the template conflicts with other
information sources utilised at
admission. For instance, medicines
prescribed by clinicians other the
GP (such as hospital doctors) or
over-the-counter medicines may
not be included in the template.
However this initiative is just one
of a number of responses to the
national guidance. Others include
expanding the pharmacy-led med-
37 Prescriber January 2010
icines reconciliation service within
the acute trust, and exploring the
use of community pharmacy medi-
cines use reviews (MURs) as a
source of medication histor y for
elective surgical patients. For all of
these developments, the intention
is to assess the impact resulting
from what is believed to be an
improved service for patients.
References
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Ian Nicholls and Michael Wilcock,
both of Royal Cornwall Hospitals
NHS Trust and previously of NHS
Cornwall and Isles of Scilly at time of
writing
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