Hi Ali,

I mean "Healthcare Setting"its a typing error,apologies.

Dear Sultan,

In the UK this activity is expected to be done with all patients who are admitted and come into contact with a pharmacist or pharmacy technician. Using ideally 2 sources of information (patient, medicines themselves, previous notes/prescriptions etc) a full and accurate list can be made and confirmed by the pharmacist which helps address any problems at the first instance.

Regarding feasibility in my opinion there are significant issues relating to staffing, expectations of the pharmacists' role. cultural aspects, availability of information etc. Not an easy collection of things to overcome but I think you will agree a worthwhile goal to get to!

Good Luck

In secondary settings, e.g. hospitals it is feasible on admission, it might be done by pharmacists (ideally) or by trained nurses/physicians using checklists. Another challenge is the availability of sources at admission, we have here in Norway not enough transmission of electronic prescription data etc. so if the patient is not able to provide information it might be challenging to get the correct list of medications. 

If resources are scarce I would have tried to prioritise who should receive the service, so elderly with many medications, warfarin patients, and transplant patients etc could be prioritised to get the maximum impact of resources spent.

Dr. Svendsen, your focus on the elderly, multiple medications, and low therapeutic index drugs like Warfarin and immunosuppresives is very important.  I would add opioids and chemotherapepeutic agents as well.

In my opinion, reconciling medications after a pt has been discharged from the hospital and their medication regimen changed is a critical time to determine if the pt has continued the new set of meds or doses.  This is especially of concern in the elderly or those on limited incomes.  Difficulty in understanding new prescribing issues and problems with reading labels significantly complicate compliance with new medications after hospital discharge.

The question of who should call the pt or follow up is always a concern.  Adding another step to reconcile medications means more work for someone and moving a RN or PharmD from one funtion to another, leaving a gap in the vacated position.  Adding another person, costs the hospital more money, although the cost may be justified by the reduction in medication errors, relapse rates, and hospital re-admission rates, especially in view of the "30-day rule."

As much as I recognize thses problems, as a clinical pharmacologist dedicated to improving therapeutics, I stronly support reconciliation of medications.  Besides, the Joint Commission monitors for this and does want to see its certified hospitals doing this on a regular basis.  Rehab facilities and other interim pt care also facilities must ensure that new medication regimens are institued, and that pts receive adequate instruction in complying with their new medications and doses.

The resources is a main issue in the Med Reconciliation, though it takes lot of time from the Pharmacists, i still feel they are the right person for the job. So the stake holders should put the system in place and employ adequate number of trained and qualified pharmacists.  

I couldn't agree more, Dr. Salah.  And, thank you for your comments.  If you send me your email, I will send you a copy of my paper on medication error reduction.  Please email me at: medlaw@doctorbenjamin,com.  If you have the time, please visit my newly designed website at www.doctorbenjamin.com.  

Please continue to post your  insightful comments.

My hospital Providence Regional Medical Center in Everett, Washington USA utilizes specially trained pharmacy technicicans who interview the patient and their family if available, utilize insurance records, contact outside pharmacies and electronic records available thru affliated hospitals and clinics in our area.  Currently this is done for every patient admitted thru the Emergency Department between the hours of 0700-2300 every day.  For patients admitted directly from a clinic or transferred from another facility, the nurse completes the Med Rec.  If a provider encounters a problematic med rec that was not completed by the pharmacy department, the provider places an order for a med rec consult. 

At discharge the provider uses the inpatient medicaiton list and the admission med rec to determine which medications the patient will take after discharge. For patients who meet our Transistion of Care criteria, they may also receive discharge counseling from the TOC pharmacist who goes over each medication and answers any questions the patient or family may have.  This is a new program for us and we are currently targeting patients with CHF and COPD Mon-Fri dayshift hours only at present.  Our ambulatory pharmacy is in the process of implementing TOC post discharge followup and will contact the patients after discharge.  For patients who are serviced by Everett Clinic, a large clinic organization that is outside of our physician group but works closely with our hospital, we provide our TOC pharmacist progress note directly to their TOC ambulatory pharmacist team for follow-up after discharge.

The success of Medication Reconciliation depends upon your staffing resources as well as the availability of information such as insurance records or pharmacy records to confirm the information provided by staff.  The use of various electronic healthcare programs can be very helpful.  When data is input into the hospital med rec, the database can be confusing and a little overwhelming to non pharmacy personnel such as nurses who may not understand which product to select (immediate release formulations, extended release formulations, etc come to mind immediately).  Data imported from outside sources such as a clinic or provider's office will only reflect that last prescription written and may not reflect a dose or direction adjustment that has occured since the initial prescribing (eg the frequent dosing changes with warfarin or furosemide).  Some educaiton for such personnel including what information is on the prescription vial including formulation designations such as XR or gel-forming that need to be included in a med rec, strength versus dose distinction etc may be helpful as well.  Education of the patient and family is also important, especially as many patients bring in hand-written lists which are often incomplete.