Medicines Reconciliation Protocol


This protocol aims to ensure that, by undertaking accurate medicines reconciliation
  • The right patient receives the right medicine, at the right dose and at the right time
  • The risk of medication errors are reduced when a patient moves from one care setting to the next
  • Patients receive personalised medicines management care, thus promoting a patient centred approach
  • Roles and responsibilities of healthcare professionals in medicines reconciliation are defined
  • For weekly/monthly treatments provide the day of the week or date of last dose
  • Discharge letters /summaries should be work flowed within 24 hours of receipt to the practice pharmacist
  • Medicines should be reconciled within 2 working days of receipt by practice pharmacist unless red flagged in which case 24 hours
  • Any changes to medication should be documented and acted upon
  • If there is any ambiguity about medication changes the GP surgery should contact the appropriate prescriber/ward as soon as possible to clarify
  • Call 01273 696955 Ext. 3696 for hospital discharge summary queries 
  • Any changes to medication should be discussed with the patient/patient’s advocate if appropriate by telephone or by sms
  • If a compliance aid is in use, inform the community pharmacy of any changes
  • If the patient is housebound make appropriate arrangements as neccessary
  • Assign diagnosis on all new medications
Drugs that require special attention
  • Warfarin
    • fill out warfarin template
    • ensure patient has been referred to CPAMS or RSCH Anticoagulation Clinic
  • Insulin
    • Use brand names
    • I dose and timings in relation to meals.
  • Steroids
    • along with dose, record the length of course, whether it is long term maintenance, a short course or a reducing course
  • Shared Care Medications
    • Azathioprine, Salazapyrin, Mycophenolate, Methotrexate, Lithium
    • in script note add BT frequency and test details & add a note on patient home screen to clearly identify patient is on a high risk medication - these are in presets
    • check that there is already a shared care document in patients records and make a note of this in home screen
    • if there is no shared care agreement patient will need to be refered to rheumatology, neurology or mental health fast tracked to get this prescribing started
    • discuss with patient 
    • do not add to repeat template until shared care agreement in place
    • send patient letter about shared care agreement
  • Depot injections
    • Denosumab, goserelin
    • record dose and frequency and date of next dose
    • Issue next prescription
    • Send a task to nurses
  • Hydroxocobalamin
    • add to repeat template
    • identify next due date
    • DO NOT issue prescription
    • send task to nurses
  • Sustanon
    • add to repeat template
    • dentify next due date
    • issue prescription?
    • send task to nurses
  • Opioid substitute therapies/substance misuse
    • minimise risk of dose duplication, overdose or diversion
    • ensure continuity of prescribing
    • liaise with community pharmacy to confirm current dose and time/date of last administration 
Check if the new medication needs monitoring 
  • Make a note on medication record or PMR
  • Inform patient
  • Task receptionist to arrange any appointments neccessary 





Warfarin Azathioprine Salazapyrin Mycophenolate Methotrexate Lithium goserelin Hydroxocobalamin

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