Medication errors are a common and significant problem, with discrepancies particularly prevalent on admission to and discharge from the hospital. Since 49% of prescribing discrepancies occur at admission, it is integral for the entire health care team to support the process of medicines reconciliation to prevent avoidable errors.
Medicines reconciliation enables health care professionals to differentiate errors from intentional discrepancies. Unintentional discrepancies, such as eye drops or inhalers omitted from charting due to inaccurate medication histories, would be considered avoidable errors. Undocumented intentional discrepancies can also occur. For example, a prescriber may cease an antihypertensive on admission with an undocumented intention to restart the medicine on discharge. Though the prescriber’s intentions are being fulfilled as an inpatient, there is a risk of error upon discharge if the medicine is not restarted. Clear documentation of the prescriber’s intentions could avoid these types of errors. In an ideal situation, patients would receive medications entirely as intended.
The formal definition of medicines reconciliation is “a process for obtaining and documenting a complete and accurate list of a patient’s current medicines upon admission and comparing this list to the prescriber’s admission, transfer, and/or discharge orders to identify and resolve discrepancies.”
The medicines reconciliation process consists of four key steps:
- Obtain and document the best possible medication history;
- Confirm medication history;
- Reconcile the history with prescribed medicines and follow up discrepancies; and
- Supply accurate information when care is transferred.
To streamline the process of reconciliation, the Australian Commission on Safety and Quality in Healthcare (ACSQHC) designed a standardised form for collecting pre‐admission medicines and reconciling variances that should be kept with a patient’s medication chart for easy access. The Medication Management Plan (or MMP) form contains four pages with sections for the best possible medication history, sources for confirming the medication history, reconciling the history with charted medicines, documenting the prescriber’s plan, and rectifying any discrepancies or problems.
There are also sections for documenting patient’s medication management issues, such as the use of a dose administration aid (DAA), and recent changes to medications prior to admission or on transfer to another health care facility. It has been shown that improved documentation and communication through the completion of the MMP form, can significantly reduce medication errors and improve patient outcomes. The ACSQHC provides educational material for health care professionals to integrate MMPs into their practice effectively.
Hospital pharmacists have a key role to play in medicines reconciliation as experts in medicines and their management. As highlighted in the Society of Hospital Pharmacists’ Standards of Practice for Clinical Pharmacy, the role of conducting clinical pharmacy activities, such as accurate medication histories, can greatly contribute to the completion of the MMP form and hence, the process of medicines reconciliation. The role of a clinical pharmacist also more broadly includes promoting the quality use of medicines among pharmacy and multidisciplinary colleagues. Introduction of, education about and encouraging the use of the MMP form can be a method for pharmacists to work with their health care teams for the benefit of patients.
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- SHPA Committee of Specialty Practice in Clinical Pharmacy. SHPA Standards of Practice for Clinical Pharmacy. J Pharm Pract Res. 2005; 35(2): 122-46.
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- Wheeler AJ, Scahill S, Hopcroft D, Stapleton H. Reducing medication errors at transitions of care is everyone’s business. Aust Prescr. 2018; 41(3): 73–7.