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Improving medicines reconciliation on admission



In the first of two articles provided by North Bristol NHS Trust, the focus will be on the background of medicines reconciliation and our work at North Bristol to first implement and then improve on medicines reconciliation on admission
Jane Smith
Principal Pharmacist, 
Service Development and Governance
Julie Hamer
Lead Pharmacy Technician – 
Medicines Management
Alison Mundell
Clinical Pharmacy Manager
Natasha Mogford
Specialist Pharmacist – Admissions
Robert Brown
Specialist Pharmacist – Cardiology
Frank Hamill
Clinical Audit and Assurance Manager
The aim of medicines reconciliation on hospital admission is to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission. Details to be recorded include the name of the medicine(s), dosage, frequency and route of administration. Establishing these details may involve discussion with the patient and/or carers and the use of primary care records. This does not include medicines review.(1) In the UK this process also includes the use of Patients’ Own Drugs (PODs).
Medicines review is excluded from the definition of medicines reconciliation but is a process to ensure that medicines prescribed are appropriately adjusted based on patient needs and is defined as: A structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste.(2)
Medicines reconciliation should take place on admission, on transfer and on discharge. Most NHS Trusts reconcile on discharge; however, the complex area is reconciling on admission, when information from primary care and patients and/or carers is not always easy to obtain. Patients do not always take what their doctors think that they take. Most reviews agree that between one-third and a half of medicines prescribed for long-term medical conditions are not taken as directed. This can be intentional or unintentional.(3)
Medicines reconciliation
Globally, in 2006, the World Health Organization (WHO) – began their High 5s programme. Medicines reconciliation was a target and due to the complexity and resource requirement, their focus was on patients 65 years of age and older who are admitted to an inpatient ward from the emergency department.
The Institute of Healthcare Improvement (IHI)(4) also set medicines reconciliation as one of their work streams in their ‘Saving Lives campaign’.
In the UK from 2004 to 2008, IHI together with the Health Foundation (HF) launched the Safer Patients Initiative (SPI2) They also set a target on medicines reconciliation and acknowledged that this could be a slow process due to the complexity.
The main UK national driver from 2007 is “Technical patient safety solutions for medicines reconciliation on admission of adults to hospital” guidance from the National Patient Safety Agency (NPSA) and the National Institute of Clinical Excellence (NICE).(1)
Medication errors cause harm to patients, lead to increased morbidity/mortality and inflate healthcare costs. The benefits of medicines reconciliation in improving safety and reducing costs from medication errors are emphasised in:
  • National Institute for Health and Clinical Excellence (NICE) collaborating with the NPSA.(1)
  • The National Prescribing Centre guide to implementation of medicines reconciliation.(5)
  • The PRevalence And Causes of prescribing errors in general practiCe (PRACtICe) study showed errors in one in 20 prescriptions with 30% due to incomplete information.(6)
  • The impact on patient safety focused on reducing harm and subsequent avoidable increases in length of stay (LOS). NPSA data from Nov 2003 to March 2007 showed two fatalities and 20 reports of severe harm due to lack of medicines reconciliation processes on admission or discharge.(7)
  • The Quality, Innovation, Productivity and Prevention (QIPP) programme (QIPP/Medicines and Procurement programme including Medicines Optimisation and Transfer of Care) lead to workstreams including:
Medicines reconciliation metrics: In 2011 to 2012, levels of medicines reconciliation in NHS South Central equated to a cost avoidance of £2.7m. More recently, this medicines reconciliation database has been opened up to teaching hospitals across England with the aim of having most hospitals in England using the tool by the end of the year.(8)
Claire Howard, Deputy Chief Pharmaceutical Officer NHS England, provided an updated viewpoint: “NHS England now plans to incorporate medicines reconciliation rates by NHS trusts in their forthcoming Medicines Optimisation prototype dashboard. The dashboard will highlight to CCGs [Clinical Commissioning Groups] and trusts which trusts are routinely contributing to the Medication Safety Thermometer and if so, their reported medicines reconciliation rate. This dashboard will help commissioners and providers to think about the use of medicines in general terms rather than just a focus on their cost.”
Many articles show some outcome measures of the benefits of medicines reconciliation that can be difficult to quantify(9–18) – and as from the main references above(1,4,5) – these benefits should now be accepted. There are, however, fewer articles on process measures covering the practicalities and difficulties of and results from improving medicines reconciliation on admission. Of these, some are from single measurements on one or a limited number of wards.(19–26)
North Bristol NHS Trust 
North Bristol NHS Trust (NBT) is a large, acute teaching Trust based on two sites at Frenchay and Southmead Hospitals with approximately 1,050 beds, 50 wards and 9,100 staff.
NBT was selected as one of only 22 trusts to take part in the SPI2 from 2007 to 2009.
When the SPI2 finished, the South West region initiated the Southwest Quality and Patient Safety Improvement Programme (SWQPSI) from 2009 to 2013 based on the SPI2 model, and this became a regional exemplar and is now the Safer Care NHS South West programme with the West of England Academic Health Science Network.
Despite working across two sites and the restrictions that brings, we have produced good results. However, we are looking forward to our new ‘super’ hospital in May 2014 and the opportunities and challenges that will bring.
The pharmacy co-ordinates the ‘Patient Safety – Medicines Management workstream’ and our team also carry out improvement work on other topics, including missed doses and anticoagulants.
As above, this project formed part of our work with the HF/IHI SPI2 (2007–2009) and SWQPSI (2009–2014).
The aim was to improve medicines reconciliation. The objective was:
  • Increase to more than 95% the number of patients receiving medicines reconciliation within 24 hours of admission.
Although we thought we knew that medicines reconciliation occurred, the initial challenge was to prove this and establish processes to enable data collection.
We achieved our results by adopting SPI improvement methodology starting with the use of the Model for Improvement and ‘Plan, Do, Study, Act’ (PDSA) cycles and tests of change on one ward. We established ongoing tests of change with ongoing measurement mapping with the use of run charts to spread and embed in our organisation through different phases.
Phase 1: Feb 2007–July 2008: SPI2 (1–8 wards)
We liaised with medical staff on one ward to introduce a ‘Medicines Admissions proforma’ to instigate data collection and developed an eAudit tool. The proforma allows an accurate record of medicines reconciliation. The clerking doctor carries out the initial medicines reconciliation completing the proforma. This is followed by a pharmacist performing medicines reconciliation and writing in the proforma. The collection of data was carried out by pharmacy support staff.
The project team gained knowledge of improvement methodology on the SPI2 programme and then trained frontline ward staff. It was important to involve frontline staff in PDSA cycles and drive the project through core team meetings with executive support.
Work and information was publicised using dedicated Patient Safety Notice Boards and ‘Toilet Top Tips’ (educational posters for a captive audience used across the Trust!!)
Phase 2: Aug 2008–July 2009: SPI2 (8–11 wards)
A DVD was designed for training medical students and doctors on medicines reconciliation (available to buy).(27) We consolidated practices and involved more staff to continue to embed and spread.
We analysed elective and emergency admissions data to spread to wards where admissions were >2% of the total number of admissions to NBT. We collected randomised data electronically as a run chart and improved communication with patients, ambulance staff and general practitioners (GPs).
Phase 3: Aug 2009–Feb 2011: SWQPSI (11–30 wards)
Successes enabled new posts to spread service to a new high-risk area. Work then started to focus on more difficult areas.
In 2010, tests of change on accuracy of Medicines Reconciliation, were carried out and spread to 42 wards.
Phase 4: Feb 2011–now: SWQPSI (31–15 wards) Target achieved 
We re-analysed elective and emergency admissions data to ensure they were collected from the most appropriate wards. In 2012 we also started to separate Sunday data to ensure the day of admission did not adversely affect our results.
In 2012 following a successful trial of a surgical pharmacist in the pre-admissions clinic, ongoing funding was agreed. We also started work with the pre-op nurses to improve their performance in medicines reconciliation in those clinics that do not have a Pharmacist present.
Data collection
Initially we audited just the medical admissions ward as we had support from medical staff in this area together with specialist admissions pharmacists already in post. We had also assumed that most of our admissions would occur through the admissions wards.
When we were ready to spread to other areas, we reviewed admissions data for each ward over the past year. These data are now reviewed on a 6-monthly basis or earlier if we have had ward movements due to changes in planning for our new hospital.
Each week our Medicines Management Technicians (MMTs) identify patients to audit depending on admission date on their wards and complete the data collection form. The form shows:
  • Week commencing date when audit being undertaken;
  • Date of admission (previous 48 hours);
  • Patient identification code; and
  • If medicines reconciliation has been completed and date completed – helps to determine if completed within 24 hours after admission.
MMTs randomly audit five patients per week. For wards where the data have been consistently good over a 6-month period, we have reduced the sample size to ten patients per month. The form is kept on the ward and returned to pharmacy on a Friday to be uploaded weekly onto the eAudit tool developed by our Clinical Audit department.
Data currently include patients admitted Sunday to Friday. We plan to audit patients admitted on a Saturday when we extend our clinical service and opening hours in May 2014.
A monthly report is generated by the Clinical Audit department showing data related to each ward, each site, whether the medicines reconciliation was completed (yes/no) and whether the patient was admitted on a Sunday (yes/no). These data are also displayed on the Trust Quality Synopsis dashboard together with other safety data.
Initial findings
When we started on one ward, we thought that if we trained the doctors effectively and wrote a good standard operating procedure (SOP) then our results would improve – but it was obvious at an early stage that ‘spray and pray’ would not maximise our results. This was mainly due to the large numbers of rotating junior doctors and their other competing workload priorities. It was the combination of medical and pharmacy input provided the best results and our ‘gold standard’.
We also assumed that most of our admissions would occur through the admissions wards but were surprised to find that in 2007 this accounted for only 18% of patients and that admissions occurred on all wards to varying degrees. Results showed that 80% of admissions occurred on 20% of wards and so Medicines Reconciliation data collection therefore focused on wards with >2% of total admissions.
Medicines reconciliation
NBT data
Our run chart, enabled by developing an electronic data collection tool, shows our improvements.
The run chart shows the gradual spread of our work through the phases increasing the numbers of wards and the ongoing improvement to more consistent and less variable results. We achieved and have since maintained our target of 95% of patients reconciled from February 2011.
The run chart also highlights that medicines reconciliation is a complex intervention and this takes time to embed through the organisation to ensure sustainability.
QIPP benchmarking data
Data from the national QIPP benchmarking scheme show the percentage of patients reconciled from all participating trusts.
It highlights just how consistent NBT results (red line) are on up to 30 wards and how far we have come in our journey. Many other trusts are at the beginning of their journeys and those that have better results may be collecting data from one or limited wards.
 The QIPP data based on research developed in Sheffield,(28) shows cost avoidance associated with the medicines reconciliation process (see Fig 10).
The red line is the monthly cost avoidance for NBT and the dotted green line represents the cumulative data. We are consistently achieving approximately £30K a month and £350K a year.
Patients’ own drugs 
In order to optimise the medicines reconciliation process, we need to maximise the re-use of PODs and this has the added advantage of reducing wastage.
NBT was the first Trust in the South West to start to re-use PODs in 1992. Nationally we are unique in having ongoing data over such a long period. This shows the amount of PODs being re-used and the cost savings this brings rather than estimations from snapshot audits.
Since 1992 we have saved over £4 million, with the bulk of the savings
being made since we started to spread medicines reconciliation:
We have enabled this by liaising with ambulance staff, exhibiting posters in GP surgeries and community pharmacies and by improving communication with patients about PODs. Patients now have an increased opportunity to discuss their medicines and positive feedback has included: “I’m really grateful that you sorted my medicines for me.”
NBT data 
NBT invested in many Patient Safety initiatives and it is difficult to attribute specific results to our work on medicines reconciliation, but we are confident that our initiative contributes to NBT’s reduced harm, improved outcomes and reduced LOS. From 2007 to 2012:
  • LOS reduced: 5.8 to 5.2 days.
  • Hospital Standardised Mortality Ratio [Dr Foster’s ‘Good Hospital Guide’] reduced: 96.8 to 85.8 (national average 100). NBT is in the top quartile.
NBT practices
At NBT medicines reconciliation is a priority and every pharmacist is involved in medicines reconciliation. Many changes have been put in place to improve the process:
  • An admissions booklet is used for medical clerking and one section of this is the ‘medicines proforma’ for recording medicines reconciliation. A procedure has also been written for medicines reconciliation covering the role of doctors, nurses, pharmacists and MMTs. Our trust policy states that medicines reconciliation should involve a least two sources of information from a list of suitable sources.
  • MMTs highlight any discrepancies to the pharmacist. The pharmacist resolves these by referring to the doctor when appropriate, and highlights less-urgent ones to the doctor with the pharmacy intervention sticker attached to the drug chart. Pharmacists complete the medicines proforma and add appropriate endorsements on the drug chart.
  • Pharmacists are involved in training of doctors and nurses to improve medicines reconciliation.
– A DVD was designed about medicines reconciliation and this is shown to all junior doctors on induction.(27)
– Junior doctors working on the acute admissions unit (AAU) now shadow an admissions pharmacist to see how they perform medicines reconciliation.
– Pharmacists are now involved in training nurses who are involved in pre-op clinic to improve the quality of their involvement in the medicines reconciliation process.
  • NBT continues to audit processes so that further improvements can be made – but measurement never stops.
Role of MMTs
The role of the MMT is to identify the availability of information in order for the pharmacist to complete the medicines reconciliation process.
MMTs use a variety of sources (at least two) and checks these against the inpatient prescription chart. MMTs check the medical notes for GP referral information, interviews the patient to determine if PODs are available and checks the patient’s knowledge of their medication. This information is fed back to the ward pharmacist. Where patients own drugs are available, the MMT record the details on designated paperwork, this is then used by the ward pharmacist. If the quality of the information obtained is questionable, a fax from the patient’s GP is obtained.
Of our MMTs, 50% are trained to complete the medicines reconciliation and are accredited using the training package available from South West Medicines Information and Training. Accreditation enables the MMT to be more involved in the medicines reconciliation process and enhances their role and job satisfaction.
Main factors in our success
There are various factors that have contributed to our success:
  • By embedding our work through the Medicines Governance Group we have access to a wide range of staff and the group has also included patient panel representatives for nearly 5 years who add a more complete perspective.
  • Since the start of SPI2 in 2007, all Trust executives have been engaged to support all the projects and there is feedback through the Quality Committee. Each project has a named executive to support the work.
  • Our work involves ongoing measurement as demonstrated in the model for improvement and we are constantly extending our work with tests of change looking at e.g. weekend data and the quality of the medicines reconciliation process.
  • We reviewed and improved current practices introducing Key Performance Indicators. The admissions wards now receive twice-daily visits ensuring more patients receive medicines reconciliation at the point of admission.
  • We annually review patient admissions data to ensure our data are collected from appropriate wards and when wards achieve consistent results we reduce but do not stop data collection.
  • We record pharmacist interventions on an ongoing basis
  • Clinical Audit support has been invaluable and enabled us to have data portrayed in clear run charts, broken down to ward level and displayed on the Trust Quality dashboard for all to see.
  • As new staff joined the Trust, training continued to spread. NBT arranged Quality Improvement days for internal and external staff, where improvement methodologies were explained and project successes demonstrated.
  • SPI2 was an invaluable arrangement with support from experts and peers to understand improvement methodology; learn from others and ‘steal shamelessly’!! SWQPSI adopted this arrangement and is now an exemplar. Frank Federico, Director (IHI), supported and continues to support our work.
  • ‘Tests of change’ evolve the best ways of working, refining with spread. The ‘buy-in’ of staff is vital, starting with the enthusiasts and leaving the laggards who often change with peer pressure.
  • It is tempting to spread too quickly, so it is important to plan, continue to embed and gain support as the project evolves. Increased staff involvement improves sustainability, embedding into routine work and lessens the main barrier of time.
Sharing best practice
IHI still support our success. We are now publicising through awards, posters, articles, conferences and QIPP benchmarking:
  • Finalist in Lean Healthcare Academy Award (2014)
  • Finalist at the National Patient Safety Awards (2013)
Presented at: 
  • Pharmacy Management National Forum, London (November 2013)
  • SPI2 and SWQPSI events (2007–2013)
  • NBT Patient Safety Events/world cafes (2007–2013)
Posters at: 
  • Patient Safety Congress, Birmingham (May 2013)
  • European Hospital Pharmacy Conference, Paris (March 2013)
  • Pharmacy Management National Forum, London (November 2012)
  • British Renal Society/Renal Association Conference (May 2010)
  • UK Clinical Pharmacy Association Conference (November 2010)
Article published: On using a DVD to educate doctors.27
Observational: Visits/discussing concerns to support other Trusts.
Current unpublished work:
  • Medicines reconciliation in pre-admission clinics:
– Introduction of funded surgical pharmacists;
– Focus on clinics where no pharmacist funding is available;
– Improving nurse practices; and
– Analysis of the quality of medicines reconciliation.
Future work:
  • Pharmacists and MMTs are currently involved in the admissions unit in a pilot using connecting care; and
  • Extending clinical services to the emergency zone (AAU) on Saturdays and Sundays from June 2014.
We have also shared work by visits from other Trusts, and sharing resources of documentation and have sold our DVD. Frank Federico, Director, IHI:
“Congratulations. Not only have you improved care for your patients, you are now teaching others. That is the mission of IHI. Thank you for bringing that forward.”
From February 2011, we achieved, maintained and have improved our 95% target on up to 30 wards.
Nationally – we are the best performing Trust in England and Wales as shown by QIPP Benchmarking, with associated savings of £350K/year. Clare Howard Deputy Chief Pharmaceutical Officer NHS England: “North Bristol Trust are to be congratulated on their impressive journey to improve medicines reconciliation rates. Their work brings to life how improvement methodology can be applied to medication safety to ensure better care and improved outcomes for the patients in our hospitals.”
Globally – There are limited data explicitly showing success in many areas but possibly we are the one of the best performing trusts in the world. Frank Federico, Director, IHI:
“Your efforts inform us that, as difficult as medication reconciliation may be worldwide, it is possible to succeed.”
We are successful in carrying out medicines reconciliation and providing better quality service for our patients, reducing harm and consistently returning suitable PODs and also showing savings.
At the Patient Safety Congress (May 2013), we highlighted that the QIPP benchmarking data highlights missed opportunities for all Trusts as our systems could be transferrable. We discussed ways of improving sharing of data and methodology and are positive this will be taken forward with the QIPP work initiated by Clare Howard, Deputy Chief Pharmaceutical Officer, NHS England.
This first article was written for publication in an earlier issue, which was not published because of a schedule change. It has not been updated and, for example, refers to the future launch of the Medicines Optimisation Dashboard – which was launched in June.
Key points
  • Nationally, we are the best performing Trust – as shown by Quality, Innovation, Productivity and Prevention (QIPP) Benchmarking, with associated cost avoidance of £350k per year.
  • In February 2011, we achieved our 95% target and have subsequently maintained and improved on up this in up to 30 wards.
  • We have used quality improvement techniques and segmented patients to develop reliable processes to ensure that medication reconciliation is completed.
  • Improvement methodology is critical – and as from the ‘Safer Patients Initiative’ (SPI2) – we can ‘learn from others’, ‘steal shamelessly’ and ‘share success’.
  • Continuous Measurement is a MUST – to know we are achieving results. SPI2 quoted: W. Edwards Deming: ‘In God we Trust – all others MUST bring data!’
  • Spread is crucial to successful improvement, but practice must be embedded successfully before spreading too quickly.
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  2. “Room for Review – A guide to medication review: the agenda for patients, practitioners and managers”: Task Force on Medicines Partnership and The National Collaborative Medicines Management Services Programme (2002).
  3. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organisation. World Health Organisation, 2003 and other references in Horne et al. Concordance, adherence and compliance in medicine taking: Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) December 2005. (accessed 7 April 2014).
  4. IHI website – re Medicines Reconciliation. Available at: (accessed 7 April 2014).
  5. Medicines reconciliation: a guide to implementation. National Prescribing Centre (March 2008). (accessed 7 April 2014).
  6. GMC report. PRevalence And Causes of prescrIbing errors in general practice. May 2012.
  7. NPSA website – re Medicines Reconciliation. (accessed 7 April 2014).
  8. Report and Action Plan of the Steering Group on ‘Improving the use of medicines for better outcomes and reduced waste: An Action Plan’: Robert Darracott and Robert Johnstone Co-Chairs (October 2012).
  9. Buckley MS et al. Impact of a clinical pharmacy admission medication reconciliation program on medication errors in ‘high risk’ patients. Ann Pharmacother 2013;7(12):1599–1610.
  10. Becerra-Camargo J et al. A multicentre, double-blind, randomised, controlled, parallel-group study of the effectiveness of a pharmacist-acquired medication history in an emergency department. BMC Health Serv Res 2013;13:337.
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  12. van den Bemt PM et al. Effect of medication reconciliation on unintentional medication discrepancies in acute hospital admissions of elderly adults: a multicenter study. J Am Geriatr Soc 2013;61(8):1262–8.
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  24. MacLaren A. Medicines Reconciliation in Hospital: “Good Practice Guidance” Greater Glasgow and Clyde, Feb 2014. (accessed 7 April 2014).
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