Medicines reconciliation – accurately listing a resident’s medicines

For prescribers and all staff responsible for medicines reconciliation in residential and nursing homes.      

You can download a full pdf version of this document by following the link on the right.

What is medicines reconcilliation?

It’s the process of identifying an accurate list of a person’s current medicines. It also involves:

• comparing them with the current list in use
• recognising and resolving any discrepancies
• documenting any changes.

Medicines also includes over‑the‑counter or complementary medicines. You must resolve any discrepancies as soon as possible to ensure safe and effective patient care.

You must compare medicines with information from sources including:

• GP surgery patient records
• repeat prescription slips
• hospital discharge letter
• community pharmacy patient medication records
• care home medicines administration record.

Background

A number of reports ¹ identified high levels of medication errors that occur when people transfer between care settings. Older people, often taking multiple and complex regimens are some of the most vulnerable. When people move from one care setting to another, between 30% and 70% of patients have an error or unintentional change to their medicines².

National Institute for Health and Clinical Excellence (NICE) highlighted the importance of medication reconciliation.

Why is medicines reconciliation important?

It helps to³:

• avoid omission of medications
• make sure there are no delays to critical medicines such as anticonvulsants, anticoagulants, antidiabetics, and for Parkinson’s disease
• avoid errors in resident’s receiving the wrong dose, strength, or formulation
• avoid the risk of adverse drug reactions and interactions.

Purpose

This information will help to:

• ensure that care home residents get all intended medication (and no unintended) medication following a transfer to and from the care home
• provide a framework for staff to do medicines reconciliation for residents who’re admitted to and discharged from the care home.

What is the medicines reconciliation process?

Care homes should follow the three steps (3C’s) to medicines reconciliation.

Collecting

You must:

• collect information about the resident’s medicines
• use the most recent reliable sources (at least 2) – see the table below
• identify and record any discrepancies.

Checking

You must:

• check the medicines and doses prescribed match
• if they don’t match, investigate and resolve any discrepancies.

Communicating

You must:

• document how any discrepancies were resolved
• accurately list the residents medicines and communicate.

Most reliable information sources for medicines reconcilliation	Least reliable sources
Recent and dated computer print-out from a GP clinical records system	Medicine administration record (MAR) sheets
Recent and dated patient’s repeat prescription request slip	Community pharmacy patient records
Recent and dated hospital discharge summaries (check that all the patients medications are listed, not just those which were changed during the hospital stay)	Care plans
Verbal information from the patient, their family, or a carer	Care home managers
Residents own drugs (check dispensing dates)	A monitored dose system(MDS) and other compliance aids
	A medicines reminder

Important points to remember

You must get residents consent when getting information (refer to the care homes consent policy).

If there are communication difficulties in getting information from the patient/carer, there should be more than one method of ensuring information accuracy. You should use alternative methods of communication, for example interpreters, writing, or sign language.

Record the information collected and its source if you use the medicines reconcilliation form (see pdf on the right for this form).

Document any sources that you attempt to access even if they’re unavailable.

Who should be involved with medicines reconciliation process?

Any healthcare professional⁴ can do medicines reconcilliation, if they’re competent to do it and have the skills and information they need.

Others who should be involved in medicines reconciliation include:

• the resident and/or their family members/carer
• a pharmacist, or other health and social care practitioners involved in managing medicines for the resident.

What should care homes do to make sure the medicines reconciliation process is safe?

This includes:

• having an up-to-date medicines policy that includes written processes for accurately listing a resident’s medicines⁵
• establishing who has responsibility for the process
• recording the details of the person completing the medicines reconciliation (name, job title, date)
• completing a personalised medicines reconciliation form (see Appendix 2) as part of the reconciliation process.

The person responsible for a resident’s transfer assessment into a care home should coordinate the accurate listing of all the resident’s medicines. This must happen as part of a full needs assessment and care plan, and consider the resources needed for this to happen in a timely way.

When should medicines reconciliation happen?

Within 48 hours at transfer of care including:

• admission into residential/nursing
• hospital admission (planned and emergency)
• hospital discharge
• transfer within the same care home, for example, from one unit to another, from residential unit to nursing unit
• discharge from care home to community.

What information should be available for medicines reconciliation?

This includes:

Resident’s details

Including full name, date of birth, NHS number, address, and weight.

GP’s details

Current GP and previous GP if the resident recently changed GP.

Relevant contacts defined by the resident /carers

For example:

• family members
• consultant
• regular pharmacist
• specialist nurse
• care home nurse lead for this individual.

Known allergies

Also reactions to medicines or ingredients, and the type of reaction experienced if known.

Current list of medicines

Including names, strength, form, dose, timing and frequency, route of administration and indication. This should include both prescribed medicines and those bought over the counter.

Recent changes to medicines

Including medicines started, stopped or dosage changed and the reason for the change.

Date of the last dose of any medicines

When this was taken, if given less often than once a day. This includes ‘when required’, weekly, monthly, and quarterly medicines.

Other information

For example, when the medicine should be reviewed or monitored. Also, any support the resident needs to carry on taking the medicine, for example:

• compliance aids
• the consistency of thickened fluids needed for those with swallowing difficulties
• details of flushes before and after medicines in PEG fed residents.

References

1. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes
2. Keeping patients safe when they transfer between care providers – getting the medicines right
3. Patient safety and quality: an evidence based handbook for nurses
4. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes
5. Accurately listing a resident’s medicines (medicines reconcilliation)
6. Medicines reconcilliation