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

Workflow

• 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