9.3 Medicines reconciliation
Medicine reconciliation is about obtaining the most accurate list possible of patient medicines, allergies and adverse drug reactions (ADRs). By using this information within the practice as well as across the health sector, it will ensure the safe and effective use of medicine.
|Standard - what we'll be assessing on||Evidence to provide for assessment|
9.3 The practice undertakes medicines reconciliation in a timely manner.
Communication between health professionals is key to the medicine reconciliation process and will significantly reduce medication errors caused by incomplete or insufficient documentation and will also reduce errors that could otherwise cause harm to the patient.
The Health Quality and Safety Commission (HQSC) have produced the Medicine Reconciliation Standard which has been endorsed as the Standard for the New Zealand health and disability sector by the Health Information Standards Organisation (HISO), a committee that reports to the National Health IT Board.
The Standard applies to any person or organisation that provides medicine reconciliation within the New Zealand health and disability sector. It applies to both the paper and electronic medicine reconciliation process.
Summary of the HQSC Medicine Reconciliation Standard
1. Accountabilities and Responsibilities
- All registered healthcare practitioners involved in medicine reconciliation are responsible and accountable for the accuracy and quality of information provided to support the medicine reconciliation process at a given point in time.
- Each organisation ensures each healthcare practitioner involved in the medicine reconciliation process is able to undertake their role and responsibilities competently
2. Medicine Reconciliation Processes
- Collect: The healthcare practitioner collects the most accurate list of medicines, allergies, and adverse drug reactions (ADRs) using a minimum of two source types.
- Compare: The healthcare practitioner compares the collected medicines, allergies and ADR list against the prescribed information, such as the medication chart, identifying and documenting any discrepancies.
- Communicate: At each transfer point, all changes that have occurred to the patient’s medicines, allergies and ADR lists will be documented, dated, and communicated by the healthcare practitioners involved to ensure the care of the patient is continued
- Any information associated with medicine reconciliation is complete, accurate, relevant and current. The responsibility for this remains with the healthcare practitioners involved.
4. Measuring, Evaluation and Reporting
- Measuring and evaluation: Medicine reconciliation process, impact and balance measures are undertaken at regular intervals for learning and improvement using a continuous quality improvement cycle, for example, Plan – Do – Study – Act (PDSA) cycle.
- Reporting: Each organisation ensures reporting on medicine reconciliation meets local and national requirements, for example, certification.
Systems must be in place to facilitate data collection from both patients and healthcare practitioners to measure and evaluate the success of the current medicines reconciliation process
The PDSA cycle can:
- identify areas where improvements can be achieved (auditing)
- show that improvement is being achieved
- show that improvement is being sustained
Things to evaluate and consider:
- How well are changes being implemented, for example, are timeline targets being met within 24 hours?
- What is the impact - are you achieving improvement and reducing discrepancies?
- Are the changes to improve this part of the system causing new problems in other parts of the system, for example, delays in patients receiving their medicines?
This process must continue at regular intervals with results and learnings contributing to ongoing team support and training.
Relevant learnings and changes are to be reported to the clinical governance group.
A medicine reconciliation policy ensures the right patients receive the right medications in the right dose at the right time. Reconciling medications reduces the risk of medication errors and confusion that may occur during patient transfer of care.
Medicines’ Reconciliation Policy
The practice’s Medicines’ Reconciliation Policy must include:
- Accountabilities and responsibilities, both personal and organisational
- The medicine reconciliation process:
- Collection and accurate identification of a patient’s current list of medications
- Comparing the information collected to a list of medicines recently available to the patient
- Identifying and resolving discrepancies
- Accurately recording and communicating the outcomes
- Education and training requirements:
- Included in new team training
- Audit process:
- Describe the audit tools the practice uses
- Measuring and evaluation
- Processes are audited at regular intervals followed by a continuous quality improvement cycle (for example, PDSA)
- Relevant learnings are reported to the clinical governance group
- Each organisation ensures reporting on medicine reconciliation meets local and national requirements
NB: Your practice policies/procedures, need to adhere to the general structure suggested here and include document control measures.
Clinical record reviews
Practice's may wish to utilise the clinical record review self-audit checklist to ensure that clinicians are documenting and managing patient records correctly.
Recording prescribing information electronically provides accurate, readily accessible data for continuity of patient care and an audit trail of activity.
Clear and accurate patient records contain all relevant clinical findings, decisions made, information given to the patient, and the medicines and any other treatment prescribed.
The patient record needs to include adequate patient medication history, including:
- Current medical conditions
- Any previous adverse reactions
- Concurrent or recent use of medicines (including non-prescription, complementary and alternative medicines)
Safety in practice medicine reconciliation audit example
Health Quality & Safety Commission New Zealand Medicine Reconciliation Standards
RNZCGP: Clinical record review self-audit checklist (Adobe Acrobat Reader recommended)
RNZCGP: Nurses Clinical record review self-audit checklist (Adobe Acrobat Reader recommended)