The importance of medication reconciliation for patients and practitioners

Editor, – I read the timely article by Ms Duguid on medication reconciliation (Aust Prescr 2012;35:15-9) with great interest. Prescribing is a common but often complex and challenging intervention. With a meteoric rise in the ageing population, its attendant polypharmacy and the shift of chronic disease management to primary care, the majority of prescribing will happen in primary care. The peri-discharge period can be perilous. However the article fails to mention some proven strategies in reconciliation such as:

• referring patients for a home medicines review within a stipulated period of discharge (ideally within two days) thereby avoiding rebound admissions and medication misadventures
• engaging a hospital or consultant pharmacist to liaise with the patient’s general practitioner, given that managing patients on multiple drugs can be time consuming and require delicate balancing of guidelines and clinical complexities
• checking for potentially inappropriate medicines using Beers Criteria. An Australian version of this list is currently being considered.¹

With the proliferation of prescribing rights, relevant curricula (medicine, pharmacy and nursing) need to be restructured to explicitly include therapeutics as a formal part of the training. This will build the knowledge and skill base for the quality use of medicines, ideally in an interdisciplinary milieu.

I wish to thank Ms Duguid for highlighting the magnitude of medication-related problems both in individual patients and as a public health issue. I hope there is a strong political commitment to the quality use of medicines which is a central tenet of Australia’s National Medicines Policy.

Jay Ramanathan
Physician trainee
Sydney

Margaret Duguid, author of the article, comments:

I would like to thank Dr Ramanathan for highlighting the risks of medication-related problems occurring following discharge from hospital and the value of hospital and community liaison services and home medicines reviews in the immediate discharge period. Home medicines reviews within 7–10 days of discharge have been shown to decrease the potential for adverse events in at-risk patients discharged home.²

To date, timely access to home medicines reviews in the immediate discharge period has been a limitation to their uptake.³ However, with the ability for general practitioners to refer directly to accredited pharmacists and the proposed hospital home medicines review referral pathway (due to be introduced in late 2012), some of the barriers to early post-discharge medication reviews will be removed.

Patients transferred from hospital to residential aged-care facilities are at particular risk of medication errors. Often their medicines are changed and doses of newly prescribed medicines omitted or delayed. In the case of a resident returning from a hospital admission, ceased medicines were inadvertently administered from a pre-existing medication chart.⁴ Checking the medication orders against the medicines list in the discharge summary to identify any discrepancies is an important safety practice. As Dr Ramanathan pointed out, medication reviews early in the admission provide the opportunity to identify and reconcile these discrepancies as well as review those medicines commonly known to cause harm in older patients.

Pharmacists also have an important role in checking the patient’s records when new medicines are ordered, ceased or changed and reconciling any discrepancies with the prescriber.

The Australian Commission on Safety and Quality in Health Care has a strong commitment to patient safety. Promoting medication reconciliation is one of its priorities.