Action 4.6 states

Clinicians review a patient’s current medication orders against their best possible medication history and the documented treatment plan, and reconcile any discrepancies on presentation and at transitions of care

Intent

A formal, structured, multidisciplinary and timely process is in place for reconciling medicines against the BPMH and treatment plan, which involves patients and carers.

Reflective questions

What processes are in place to ensure that clinicians review their patients’ current medication orders against the BPMH?

How and where are discrepancies with a patient’s medicines documented and reconciled?

How are changes to a patient’s medicines, and the reasons for change, documented and communicated at transfer of care or on discharge?

Key task

Implement a formal structured process to ensure that all patients admitted to the health service organisation receive accurate and timely medication reconciliation on admission, at transfer of care and on discharge.

Strategies for improvement

Hospitals

Although specific aspects of medication reconciliation may be attributable to one professional group, medication reconciliation is everybody’s business, and a multidisciplinary approach is crucial to success.

Medication reconciliation may occur:

  • On admission – matching the current medicine orders with the BPMH, ideally within 24 hours of admission

  • During the episode of care – verifying that the current list of medicines is accurately communicated each time care is transferred and when medicines are recharted

  • On discharge – checking that medicines ordered on the discharge prescription match those on the discharge plan and the medicines list, and confirming that changes have been documented.

Prioritise medication reconciliation in patients who have a higher risk of experiencing medicine-related problems or ADRs, in a similar manner to prioritising or risk assessing patients for medication review (see Actions 4.10 and 4.12).

Review organisational policies, procedures and guidelines on medication reconciliation. These should include key steps of the medication reconciliation process and when these should occur (including at transfer of care and on discharge), roles and responsibilities of clinicians, training requirements for clinicians who are responsible for reconciling medicines, the involvement of patients and carers (links to Action 4.3), and documentation requirements, including where and what should be documented.

Review existing risk assessment criteria for patients who might benefit from medication reconciliation (links to Action 4.12).

Skills and training

Only clinicians with the requisite knowledge, skills and expertise should conduct medication reconciliation. These clinicians should be able to show competence in each of the steps of the medication reconciliation process.

Consider training requirements for clinicians who are responsible for reconciling medicines.

Day Procedure Services

This action will not be applicable for day procedure services that provide evidence that they are not changing or altering patients’ medicines during an episode of care.

Examples of evidence

Select only examples currently in use:

  • Policy documents about medication reconciliation on admission, at transitions of care and on discharge
  • Tool or form (hard copy or electronic) used for medication reconciliation
  • Audit results of documentation of medication reconciliation
  • Training documents about medication reconciliation and workforce training attendance records.

MPS & Small Hospitals

MPSs and small hospitals should implement a formal structured process to ensure that all patients admitted to the health service organisation receive accurate and timely medication reconciliation on admission, at transfer of care and on discharge.

Prioritise medication reconciliation in patients who have a higher risk of experiencing medicine-related problems or ADRs, in a similar manner to prioritising or risk assessing patients for medication review (see Actions 4.10 and 4.12).

Review organisational policies, procedures and guidelines on medication reconciliation. These should include key steps of the medication reconciliation process and when these should occur (including at transfer of care and on discharge), roles and responsibilities of clinicians, training requirements for clinicians who are responsible for reconciling medicines, the involvement of patients and carers (links to Action 4.3), and documentation requirements, including where and what should be documented.

Review existing risk assessment criteria for patients who might benefit from medication reconciliation (links to Action 4.12).

Only clinicians with the requisite knowledge, skills and expertise should conduct medication reconciliation. These clinicians should be able to show competence in each of the steps of the medication reconciliation process.

Hospitals

Although specific aspects of medication reconciliation may be attributable to one professional group, medication reconciliation is everybody’s business, and a multidisciplinary approach is crucial to success.

Medication reconciliation may occur:

  • On admission – matching the current medicine orders with the BPMH, ideally within 24 hours of admission

  • During the episode of care – verifying that the current list of medicines is accurately communicated each time care is transferred and when medicines are recharted

  • On discharge – checking that medicines ordered on the discharge prescription match those on the discharge plan and the medicines list, and confirming that changes have been documented.

Prioritise medication reconciliation in patients who have a higher risk of experiencing medicine-related problems or ADRs, in a similar manner to prioritising or risk assessing patients for medication review (see Actions 4.10 and 4.12).

Review organisational policies, procedures and guidelines on medication reconciliation. These should include key steps of the medication reconciliation process and when these should occur (including at transfer of care and on discharge), roles and responsibilities of clinicians, training requirements for clinicians who are responsible for reconciling medicines, the involvement of patients and carers (links to Action 4.3), and documentation requirements, including where and what should be documented.

Review existing risk assessment criteria for patients who might benefit from medication reconciliation (links to Action 4.12).

Skills and training

Only clinicians with the requisite knowledge, skills and expertise should conduct medication reconciliation. These clinicians should be able to show competence in each of the steps of the medication reconciliation process.

Consider training requirements for clinicians who are responsible for reconciling medicines.

Day Procedure Services

This action will not be applicable for day procedure services that provide evidence that they are not changing or altering patients’ medicines during an episode of care.

Examples of evidence

Select only examples currently in use:

  • Policy documents about medication reconciliation on admission, at transitions of care and on discharge
  • Tool or form (hard copy or electronic) used for medication reconciliation
  • Audit results of documentation of medication reconciliation
  • Training documents about medication reconciliation and workforce training attendance records.

MPS & Small Hospitals

MPSs and small hospitals should implement a formal structured process to ensure that all patients admitted to the health service organisation receive accurate and timely medication reconciliation on admission, at transfer of care and on discharge.

Prioritise medication reconciliation in patients who have a higher risk of experiencing medicine-related problems or ADRs, in a similar manner to prioritising or risk assessing patients for medication review (see Actions 4.10 and 4.12).

Review organisational policies, procedures and guidelines on medication reconciliation. These should include key steps of the medication reconciliation process and when these should occur (including at transfer of care and on discharge), roles and responsibilities of clinicians, training requirements for clinicians who are responsible for reconciling medicines, the involvement of patients and carers (links to Action 4.3), and documentation requirements, including where and what should be documented.

Review existing risk assessment criteria for patients who might benefit from medication reconciliation (links to Action 4.12).

Only clinicians with the requisite knowledge, skills and expertise should conduct medication reconciliation. These clinicians should be able to show competence in each of the steps of the medication reconciliation process.