Medicines reconciliation within the context of patient safety

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Medicines reconciliation within the context of
patient safety

• Dr Bruce Warner
• National Patient Safety Agency

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What is the NPSA?

• A special Health Authority established in 2001
  following the reports An organisation with a
  memory and Building a safer NHS for patients.
• Created to coordinate efforts to identify and
  learn from patient safety incidents

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The Role of the NPSA

• Collect and analyse information on adverse events
• Assimilate other safety-related information
• Learn lessons and ensure that they are fed back
  into practice
• Where risks are identified, produce solutions to
  prevent harm

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National Reporting Learning System
International Collaboration Australia USA Europe
NPSA
Standardised reporting
NHS Trusts
PractitionersStaff
Healthcare Commission MHRA NHS Complaints NHS
Litigation Authority
Patients Carers
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Scale of the problem

• 70, 000 reports a month
• 6,000 medication related reports a month
• 78 acute trusts
• 15 community hospitals or mental health trusts
• 5 community pharmacy
• 2 from other (including GPs, Dentists etc.)

NRLS Data June 2006 to May 2007
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When do errors occur?
NRLS Data June 2006 to May 2007
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Type of error
NRLS Data June 2006 to May 2007
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Outcome
NRLS Data June 2006 to May 2007
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Increasing relevance

• Patients moving much more quickly between care
  settings
• More care being carried out in the community
  based on secondary care advice
• Increasing numbers of patients in care homes
• Reconciliation does not only apply during
  admission to hospital but to any transfer of care

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Documentation

• A key issue
• Electronic prescribing may solve many problems
  but may introduce different risks
• Reports to the NRLS show doses are often omitted
  or duplicated because of failures regarding
  communication or documentation

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Minimum dataset

• Minimum data sets as described within the
  document are crucial.
• Diagnosis and rationale for medication changes
• Should be available to more than just the
  prescriber
• CfH currently working on core dataset and who
  should have access to it

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Making use of information

• Nurse visited patient at home to administer
  evening insulin. This was done and the action
  entered into the patients notes. 2nd nurse
  arrived an hour later and gave the insulin dose
  again.
• The 2nd nurse stated that she had been in a hurry
  and had not read the patients notes.

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Transitions of care

• The safe use of medicines is a key component in
  the continuity of care
• Transitions occur at different interfaces, both
  between care settings and between healthcare
  staff.
• PSO report highlighted errors at interfaces of
  care

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Transitions of care

• Data provides examples of poor communication both
  verbal and written, using a variety of methods
  and between a range of people
• Effective communication encompasses accurate
  details about medicines

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Incident types related to communication at an
interface

• Four general themes
• incomplete or incorrect medication history on
  admission to hospital
• incorrect or incomplete discharge medicines
• poor information about medicine on discharge from
  hospital
• lack of monitoring or follow-up on discharge.

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Incomplete or incorrect medication history on
admission

• If the medication history is incomplete,
  essential medicines may be omitted both during
  the inpatient episode and when the patient is
  discharged back to the community.
• Where critical drug therapy is omitted there is
  the potential for patient harm

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Incorrect or incomplete discharge medicines

• Omissions may occur when the medication history
  of a patient is either unavailable or incomplete
  on admission or discharge, resulting in essential
  medication being wrong or left off the patients
  prescription.

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Error in clinic letter

• Patient brought back repeat Rx for amlodipine
  tablets because it was for 10mg rather than his
  usual 5mg.Patient unaware of any intended change.
  Latest clinic letter indicated strength of 5mg.
• Clinic contacted and confirmed that dose had not
  changed and should still be 5mg.

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Poor information about medicine on discharge from
hospital

• It is important that any medication regimen and
  the rationale for any changes are adequately
  communicated to patients and the people
  supporting them (including their carers, GP and
  other health professionals).

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Failure to re-prescribe

• Failure to re - prescribe cardiovascular
  medication prior to discharge . The drugs were
  correctly stopped on admission due to
  cardiovascular instability following a
  significant upper GI bleed. The patient after
  discharge became symptomatic with probable CCF,
  saw her GP who reinstituted medication,
  unfortunately the patient died at home 5 days
  after discharge.

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Lack of monitoring or follow-up on discharge

• Some medicines require close monitoring to avoid
  toxicity. If the need to monitor the medicine is
  not communicated, patients may not be adequately
  followed up resulting in potential harm. This is
  especially important with drugs with narrow
  therapeutic indices such as lithium and warfarin.

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Failure to monitor

• Patient discharged from ward on warfarin.
  Anticoagulant clinic were not informed of the
  patients discharge therefore no follow - up
  appointment was made. Patient was admitted with
  an INR of 18.1 and G.I. bleeding.

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Summary

• Reported data shows that many errors could be
  avoided by accurate medicines reconciliation
• Reconciliation needs to occur across multiple
  interfaces
• Common core datasets are essential
• Everybody's responsibility
• New NPC guide to be welcomed and acted upon to
  help make the NHS safer for patients