Transcript Pharmacy Project Indicators Workshop

Medication History Taking
and
confirming and reconciling medication
on admission
Ian Coombes
Session Objectives
– Understand importance of consultation skills
– Improve communication skills
– Be able to determine what patients actually take
prior to admission
– Learn about common ‘error traps’ in history taking
– Limitations of different information sources
– Assessment of compliance
– Consider how ‘medicines/lack of’ cause admission
– reconciliation
Effective drug
therapy
Personal views,
experiences,
seen other
patients, read
literature
Improve quality
of life
Understand pathophysiology,
pharmacology,
pharmacokinetics, EBM.
Safe drug
therapy
Aims of
Pharmaceutical
Care
Understand
multiple
pathologies,
other
pharmacologies,
appreciate
consequences of
errors, safe
practice
Knowledge of
BNF, hospital
formulary,
pharmacology,
EBM
Economic drug
therapy
Interpreting
data
Gathering
data
Problem
solving
Providing a
solution
Consultation Skills
Monitoring
outcomes
Effect
What is a Medication History?
• A record of all medicines being taken at time of
hospital admission/presentation and
- previous adverse drug events (ADEs) and allergies
- recently ceased or changed medicines
- Identifies patients’ understanding of their disease
and their medicines
- Begins to identify medicine taking behaviour ie
adherence (compliance/concordance) behaviours
• The baseline from which:
- drug treatment will be continued at time of admission
- therapeutic interventions will be made
- self-caring will continue post discharge
The Importance of Medication Histories
• 14.5% of consumers are on ≥ 4 medicines (ABS, 1999)
• 5-20% of medical admissions drug related (Roughhead,
MJA, 2000)
• On admission, up to 50% of patients have an
incomplete medicine list provided, resulting in a
medicine not being administered during the hospital
stay
(Stowasser, AJHP, 1997)
• A full medication history
– Identifies patients’ needs
– Explores the patient’s perspective of illness and its
treatment (needs and concerns)
Example of Drug-Focused Care
• Will it work
• Furosemide 80mg bd
• Adverse drug effects
–
–
–
–
Hypokalaemia
Hypocalcaemia
Hypotension
Renal Function
• Drug interactions
• Legal
• Cost
• Yes, it should do
• Dose ok
• Blood results
–
–
–
–
K+ ok
Ca++ ok
BP ok
Creatinine ok
• No other medicines
• Prescription signed
• Cheap
What sort of things are going through the mind of
Mrs CCF at the moment?
Fear of the disease
Fear of future disease management
•I’ve got heart failure, it must be the end of •I’m going to have to take medicines for
the line, I’m going to die in this horrible
the rest of my life aren’t I, what if I
hospital
forget?
•If I survive this, how am I gong to cope in •I saw something on the news last week
future? My family and friends are going to about antidepressants, are all the
get sick of me, I may as well give up now
medicines they prescribe going to kill
me?
Trust healthcare professionals
Other anxieties
•I’ve heard horrible stories about these
•Oh no, I have an appointment at the
places, people going in fit and well, and
eye clinic on Monday, they’re going
coming out in boxes
to be expecting me, I’ll never get
•What about Shipman, are they all after my another appointment
money?
By focusing care on the patient
• She is still having difficulty breathing – “I feel
like I’m drowning”
• Has to go to the toilet throughout the night,
can’t sleep properly
• Mrs CCF doesn’t know what furosemide is for
• Mrs CCF hasn’t been taking her ACE-inhibitor
at home because the patient information
leaflet scared her
General points for good consultation about
medicines
•
•
•
•
•
•
•
•
Clear purpose
Builds rapport
Builds relationship
Actively listens to the patient
Open questions
Identifies patients’ needs
Full medication history
Explores the patient’s perspective of illness and
its treatment
Obtaining an accurate Medication History:
What does it involve?
• Structured process
– Review of sources of patient information
– Patient/carer medication history interview
– Organisation of patient data
• Confirmation
– Ensuring completeness and accuracy
• Not relying on a single source
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Medication History Interview - 8 steps
1.
2.
3.
4.
5.
6.
7.
8.
Obtain relevant patient background
Open the consultation
Confirm/ document allergies/ ADR
Take/document medication history
Undertake a thorough adherence assessment
Assess medication management ability
Confirm medication history
Reconcile medication history with medication chart
and current medical problems
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Accurate Medication History
• Structured process
- review of sources of patient information
(not relying on a single source)
- medication history interview
- organisation of patient data
• Confirmation
- ensuring completeness and accuracy
Confirming Medication History
•
•
•
•
•
•
carer/s
other doctors (e.g. GP)
community pharmacists ?
patient’s medicines/list of medicines ?
patient’s prescriptions ?
medical notes
-discharge card
-previous outpatient visit/s
(Obtain patient consent to contact other health care providers)
Benefits/ limitations of own
medication
Positive:
• Used as prompt/ prop:
– Can you show me what
you take?
– Do you take these?
– How many of these do you
take?
• Labels and dates
– Idea re adherence
– Contact details
– Multiple pharmacy
• Identify errors
Negative:
• Not all brought in:
– Inhalers, drops, injections,
patches, fridge items left
behind
– Webster packs not all
medicines included
• Doses on labels may have
changed – multiple
repeats over months
• Not all own medicines
Video
Medication History Interview 1
Observe:
• communication skills
• what is done well in the interview?
• what could be improved?
• any limitations of technique?
As you watch the video:
- write down the medicines you think the patient
is taking and what you wish to clarify
Key Messages from 2nd Interview
• Better engagement of patient
• Explained purpose of interview
• Use open rather than closed questions
- How long have you been on them?
- What do you think the medicines are for?
• More active listening – followed up answer
• Showed patient the tablets “brown bag”
• Used patient’s own list of medications
• Asked about any problems or ADRs
• Linked medication with medical history
Medication History
• For each medicine, record:
- generic and brand names
- strength; form; dose; frequency
- duration of therapy
- indication (patient’s perception)
• Any medicines started/ceased/changed? Why?
• Identify what patient is actually taking pre-admission
• Compare with what patient should be taking
- treatment gaps and compliance issues?
- possible drug related problems?
• Link medical history with treatment - anything missing?
- e.g. do you take anything for your diabetes?
Information Obtained –
interview 1
Medication (ED Dr)
Old Discharge Summary
aspirin 150 mg mane
aspirin 150 mg mane
frusemide 120 mg mane
frusemide 120 mg mane
hydralazine 50 mg bd
hydralazine 50 mg bd
GTN patch mane
amlodipine 10 mg mane
amlodipine 5 mg mane
Imdur/ isosorbide
mononitrate 120mg mane
Imdur/isosorbide
mononitrate 120 mg mane
glipizide 10mg bd
paracetamol prn
paracetamol prn
How does this compare to the next video?…
Comparison of Information Obtained
Doctor #1
Doctor #2
aspirin 150 mg mane
aspirin 150 mg mane
frusemide 120 mg mane
frusemide 40 mg mane prn
hydralazine 50 mg bd
hydralazine 25 mg bd
GTN patch mane
GTN 5mg/24hrs patch all day
amlodipine 5 mg mane
Imdur® 60 mg bd
Imdur® 120 mg mane
glipizide 10 mg bd
paracetamol prn
ibuprofen 400 mg tds
methotrexate 10 mg/weekly
(SUNDAY)
Don’t Forget
• Over the counter (OTC)
(especially NSAIDS; paracetamol +/- codeine)
• Eye drops
• Topical - patches, creams
• Inhaled - puffers, sprays
• Pessaries, suppositories
• Herbal and complementary medications
• Injections
• Intermittent treatments (weekly, monthly etc.)
• Recently ceased medications
• Previous allergies or adverse reactions
Taking the history is first step
• Now we need to link it to the patient!
Adding Value after taking the history
1. Matching medications with diagnoses
2. Are the medications appropriate?
3. Are the medications achieving what is
expected?
-
Is the diagnosis correct?
Is the indication appropriate?
Why Reconcile Medication?
63% of reported medication errors resulting in
death or serious injury were due to breakdowns in
communication, and about half of the errors
would have been avoided through medication
reconciliation
• Increased risk (3.5 fold) of preventable adverse
events
(Petersen, Ann Intern Med 1994)
• Miss 1 medicine off discharge letter 2.3 x readmission in 30 days
(Stowasser, JPPR 2002)
- The Joint Commission of Accreditation of Healthcare Organisations (JCAHO)’s Sentinel Event Database (2006)
Admission
Med
Reconciliation
Clinical
Handover
Discharge
Med
Review
Clinical
Handover
Med
Reconciliation
Clinical
Handover
Clinical
Handover
Lessons to Learn
• Underlying failure in handover/ communication
between primary and secondary care
• Reliance on one source of information for
medication history taking
• Always need to ask patients, carers, other Drs,
community pharmacists about medications
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Reconciliation of Medications
NO ß-blocker
frusemide
Left
Ventricular
Failure
NO ACE Inhibitor
hydralazine
nitrate
Reconciliation of Medications
NO oral
hypoglycaemics
NO Insulin
Diabetes
aspirin
NO ACE Inhibitor
Precipitation of Admission?
Nitrate Tolerance
Low hydralazine
NSAID
Left
Ventricular
Failure
Acute
Renal
Failure
NO ß-blocker
NO ACEI
?BP Controlled
amlodipine dose
Adherence
Question the patient on concordance/noncompliance and ineffectual medications:
– “People often have difficulty taking their pills all
the time…have you had any difficulty taking
your pills?”
– “About how often would you say you miss
taking your medicines?”
Risks v Benefits of Treatment
(Horne, 1997)
Beliefs about medicines are the strongest
predictor of how people use them
 In deciding whether to take medication many
patients engage in a risk-benefit analysis
Concerns
Necessity

 Patients’ actions might not correspond to treatment
recommendations (e.g. taking less)
Medication Management
Assess patient’s ability to manage own medicines
Risk Assessment
Level of Independence
Patient Assessment
• looks after own medicines • can read
• lives in Nursing Home
• can see/read labels
• uses dose admin. device
• understands English
• uses administration aid
• can open bottles
• uses medication record
• can measure liquids
Key Issues for Practice
• Most patients vary from prescribed regimen
- over & under dosing, OTC meds
• First histories taken in ED often not full story
• All information sources have limitations
• Consider drug-related contribution to admission
(over or under treatment)
• Consider what you are prescribing and why
• If in doubt, ask!
• Time spent early in admission may result in better outcomes
for all
Summary
• Medication histories are complicated
• The most readily available source of information
might not be the best!
• All sources have limitations
• Consider PC, PMH and signs and symptoms
• About 5-20% admissions are drug related
• THINK: NSAIDs, cardiovascular, immunosuppressive therapy, lack of concordance
Any Questions?