Medicines reconciliation

 In Feature article, Pharmacy Information

Care Quality Commission (CQC) and Healthcare Improvement Scotland (HIS) inspections have recently focused on medicines reconciliation, as this is a process that has significant effects on patient safety and the effective treatment of patients.

Medicines reconciliation is the process of obtaining a current and accurate list of a patient’s medication. This is particularly important when a patient is moving from one care setting to another to ensure the correct treatment is maintained, as NICE estimates that between 30% and 70% of patients have an error or unintentional change to their medicines.

Taking a medication history is a similar process. The difference is that reconciliation involves not only checking the medication details with the patient but most importantly validating them with more than one other source. It is also important to document and share any changes such as deletions or additions of medication to prevent errors.

The process

In Scotland, the HIS national improvement plan has a target that 95% patients will have their medications reconciled within 24 hours of being admitted. They recommend this should be done by a doctor and involve the patient as much as possible.

The primary source of information should always be the patient themselves and the medications they arrive with, and should always involve their carer. It would include any over-the-counter medication, alternative medication or any illicit drug use. After recording the patient demographics and checking allergy status, the doctor can then use this information as a basis to perform a second check, using another source of information.

  • Typically a second source would involve:
  • GP letter or phone call
  • Discharge letter or copy of prescription
  • Medicine Administration Record (MAR)
  • Community or hospital pharmacist

At this stage, the doctor can then decide to stop, withhold or continue these medications and document this, including reasons for their decisions. The medications should then be accurately copied onto the patient’s medication chart.

If medicines reconciliation does not happen within 24 hours from admission, then there has to be a process in place to make sure it is followed up by a doctor as soon as possible.

Similarly, when a patient is discharged, there must be a robust process of medicine reconciliation to ensure that the next care provider such as the patient’s GP, another hospital, or a care home is fully aware of what medications a patient is currently taking. The discharge letter should include a clear description of changes that have been made during their care and the reasons for this, and of course, be sent with the patient’s permission.

Ashtons are developing a ‘Medicines on Admission Reconciliation Form’ so that all the necessary information can be captured on one form and this is currently being piloted in two of our Scottish hospitals.

Further guidance about medicines reconciliation is available from:

NICE Guidance (NG5) Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes.

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