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Medication reconciliation is the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care.1
It is well known that prescribing errors can result in harm to patients. Medicines reconciliation when patients are admitted to hospital is a process which aims to ensure that important medicines that the patient should be taking are not inadvertently stopped, and that any new medicines are prescribed in light of complete knowledge of the medicines a patient is already taking.
Medicines reconciliation originated as part of an initiative in the WHO High 5 s programme in 2006.1 This was a project to address continuing major concerns about patient safety around the world and involved the collaboration of several countries and the WHO Collaborating Centre for Patient Safety.
The main driver in the UK, however, was from the National Institute for Health and Care Excellence (NICE) in collaboration with the National Patient Safety Agency (NPSA). They issued guidance to the National Health Service (NHS) in England and Wales on how to ensure that any medication patients take prior to hospitalisation is properly documented on admission.2 Details to be recorded include the name of the medicine(s), dosage, frequency and route of administration, and they advised that pharmacists should be involved in the process as early as possible. The WHO state that medicines reconciliation should be done within 24 h of patient admission to hospital.
Traditionally, drug histories have been taken by junior doctors admitting patients, but errors particularly involving omission of required medicines from prescriptions occur regularly. In response to the NPSA requirement, hospital pharmacy staff have been increasingly involved in checking drug histories and often use several sources of information, including the patient, family, medicines brought in from home, information from the family doctor (letters, repeat prescription slips, direct contact by telephone or accessing the patient's electronic health record), medical notes and discharge and clinic letters.
A study of medicines reconciliation in four UK NHS acute hospitals in elderly, renal and medical patients showed a discrepancy rate between the drugs prescribed on the inpatient chart and the actual drugs the patient should have been prescribed of 19.6% (mean 1.7 per patient).3 Thirty-eight per cent patients had at least one discrepancy with inhalers being the drugs most commonly missed followed by analgesia. Four discrepancies involving drugs such as insulin and warfarin could have resulted in severe injury or death. The mean time taken to conduct the medication reconciliation was 15 min though up to 60 min was needed in some cases. The family doctor was the information source most consulted in the majority of cases. This was despite the WHO recommendations that patients and families must be involved as they are most likely to be aware of medicines obtained from multiple sources.1
Ideally, more than one source of information should be consulted in order to corroborate the information obtained. Family doctor information is often thought to be the most reliable; however, this can be incomplete (eg, over the counter and complementary medicines taken by the patient are unlikely to be listed) or incorrect (eg, if the patient's therapy is changed over the telephone or they are also prescribed medicines from other sources). The more sources consulted however, the more time is needed for the process to be completed.
The benefits of medicines reconciliation are now well recognised in adult patients as it has been shown to reduce errors and readmission to hospital. The process is part of routine patient care in many hospitals in accordance with the NPSA guidance. Children, 16 years of age and below however, were specifically excluded as they ‘were outside the scope of the guidance’. Admittedly, many children in hospital are not on complex lists of medicines as many older people are, therefore problems may not be so common. It is difficult to know how many children need to take long-term medication; however, we do know that significant numbers of children suffer from long-term illnesses such as asthma, diabetes, epilepsy and eczema among many others involving pharmacological treatment. It would make sense then that the guidance should apply to them.
In a systematic review to explore the occurrence of medication discrepancies in the paediatric population, 10 studies were identified.4 The studies were heterogeneous in terms of definitions, methods and patient populations, and many had small sample sizes. Most related to admissions to hospital and reported consistently high rates of discrepancies ranging from 22% to 72.3% of patients.
Omission errors have been recognised as the most common type of error identified by pharmacists in our own region, the majority being medicines unintentionally omitted from the inpatient prescription written on admission.
Huynh et al5 describe a prospective study in four English hospitals where 32% (78 of 244) patients had at least one clinically significant unintentional medication discrepancy on admission. These had the potential to cause moderate harm in 20% (50 patients) or severe harm in 11% (28 patients). The total time required for medicines reconciliation ranged from 6 to 144 min (median 24). Given the rapid patient turnover on paediatric wards bringing many new patients each day, this carries significant workload implications; however, the few available studies suggest that medicines reconciliation is as necessary in children as it is in adults.
In addition to reconciliation on admission to hospital however, it is important that it also happens on patient discharge for both adults and children. Many patients, especially elderly ones, have their medicines changed during their hospital stay and go home confused about the new medicines they have been prescribed. Adverse drug events are a common reason for readmission in these patients.
Such problems can also occur in children who often present additional challenges with the need to use unlicensed and off label medicines on a regular basis increasing the risk of error. Problems in obtaining further supplies of these are common, with many families returning to the hospital due to problems obtaining the medicines through the family doctor and community pharmacist. Communication between tertiary/secondary and primary care sectors and education of parents are known to be key to minimising problems caused. Our own hospital has experienced several babies being readmitted following their family doctors prescribing different concentrations of preparations such as furosemide, spironolactone and captopril liquids. The families appear to have been unaware of this and continued to administer the same volume of liquid for each dose even though the bottle was labelled with the correct new volume to be given. As a consequence, 5-fold to 10-fold over or under doses have been administered by the parents at home. Several babies have consequently been readmitted to hospital with deranged electrolytes, dehydration or fluid overload. One unfortunate baby awaiting heart surgery elsewhere in the UK died from hypoxic ischaemic brain damage, hypovolaemia and furosemide toxicity following such an event. Accurate medicines reconciliation at and/or following discharge could reduce the risk of such tragic consequences.
Huynh et al, therefore, bring to our attention an important intervention. Medicines reconciliation should be mandatory for paediatric patients as well as adults.2 The importance of this being done on admission and at or closely after discharge must also be stressed.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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