How to take an accurate medication history when a patient is admitted
Obtaining an accurate medication history is an essential part of medicines reconciliation. This PRACTICE TOOL looks at how to find out what patients are really taking when they are admitted to hospital
When patients are admitted to hospital, doctors attempt to find out what medicines have been taken by the patient at home, the details of which are usually documented under the drug history section on clerking forms.
Strictly speaking, a medication history should include details of all medicines that a patient has tried in the past, but for the purposes of most hospital admissions it is usually sufficient to document details of current and recently discontinued medicines (eg, antibiotics, corticosteroids) along with details of any drug allergies or sensitivities.
Although doctors have traditionally carried out this task, studies have shown that pharmacists acquire more accurate and complete medication histories.1 In recent years, ward pharmacy technicians have also become involved in confirming medication histories as a natural extension of their role in assessing “patient’s own medicines” brought into hospital.
Importance of accurate histories
An inaccurate medication history could impact on decisions made by healthcare professionals about a patient’s care and lead to adverse events. A previously stable condition could deteriorate if a medicine is omitted or given at too low a dose for an individual patient.
Patients could be harmed if administered medicines that were previously stopped because of adverse drug reaction (ADR) or if prescribed a higher dose than that normally taken. Accurate medication history-taking can help identify potential ADRs (which are the cause of approximately 5% of all hospital admissions2).
In December 2007, the National Institute for Health and Clinical Excellence (in conjunction with the National Patient Safety Agency) published guidance to highlight the need for medicines reconciliation on admission to hospital.
The guidance describes medicines reconciliation as ensuring that medicines prescribed after admission correspond to those that the patient was taking before admission, but not covering the process of reviewing whether it is clinically appropriate to continue such medication on admission.
The guidance requires all healthcare organisations that admit adult patients to have policies in place for medicines reconciliation and to ensure that pharmacists are involved in this process as soon as possible after admission.
Obtaining reliable information
Several sources are available to help obtain an accurate medication history, none of which is 100% reliable (see Box below).
Unless it is not physically possible (eg, the patient is unconscious or confused), the patient should always be consulted as part of the medication history-taking process — since they are the ones taking the medicines. The patient’s partner or carer may also be consulted.
Although not all patients can recall every detail about their regular medicines (and they may be less likely to remember details if anxious about their admission), they may be able to recognise drug or product names from a list and confirm what they are still taking.
The following are suggested approaches to use when interviewing a patient:
- Introduce yourself and explain your role in ensuring he or she receives the correct medicines. The patient will encounter a variety of healthcare professionals during an admission and may become anxious if questioned repeatedly. A polite introduction and exchange of pleasantries can help the patient relax and can facilitate a more effective consultation; starting with “What brand of diltiazem are you actually taking?” will not help to achieve this. It may become apparent during the introduction that the patient will be unable to offer useful information about his/her medicines.
- Start with open questions, for example: “Which medicines do you take that are prescribed by your doctor?” Use closed questions to confirm details.
- Some patients may not consider inhalers, eye drops, creams or patches as medicines (because such medicines are not taken orally) and more specific questioning may be required to find out if such medicines are being used. The same may be true for over the counter products (including herbal and homoeopathic medicines). Patients may forget some medicines that they do not consider important, such as oral contraceptives or hormone replacement therapy.
- The consultation can also be used to assess patient compliance, which requires a non-judgemental approach. “I know I’d struggle to remember to take all those each day. How do you manage?” can help to demonstrate a sympathetic attitude.
Patients may bring written information about their usual medicines with them to hospital, eg, a repeat prescription or self-produced list. The patient should be asked if this information is up to date and whether all parts of the repeat prescription list have been brought in.
There are situations when the information given by the patient must always be confirmed by a second source, eg, methadone and benzodiazepine doses stated by a drug misuser.
Patient’s own medicines
Patients are encouraged to bring their medicines into hospital to aid with medicines reconciliation, prevent missed doses and reduce NHS expenditure. When assessing the patient’s own medicines, always consider:
- Some medicines may have been left at home, particularly if the patient’s admission was rushed, or he or she may have forgotten to bring in medicines stored separately, eg, a statin kept by the bedside or eye drops stored in the refrigerator.
- The doses that the patient takes may not be those stated on the dispensed label because of deliberate action by the patient (eg, if ADRs occur with higher doses) or upon advice from the prescriber, or even due to a dispensing error. It is not uncommon for patients with chronic kidney disease to have their antihypertensive medicine doses increased during a clinic visit or to be telephoned and told to increase the doses of their phosphate binders or alfacalcidol based on new laboratory results.
- The medicines brought in may not belong to the patient — he or she may have brought in the wrong medicines or “borrowed” medicines from a relative.
- The patient may not be taking the medicine at all. The date of dispensing or quantity of the medicines brought in may indicate a compliance issue.
GP surgeries should be contacted when patients cannot remember the details of all their medicines and have not brought their medicines or any written information with them.
When contacting GP surgeries always remember:
- It is often not possible to speak directly to a GP each time you contact the surgery. Although receptionists are usually obliging (and receive several such calls a day), they receive little or no training regarding medicines and may need to be questioned carefully to obtain correct details.
- The medication list might not be up to date. If a patient has recently been in hospital or seen in an outpatient clinic there may be a delay in updating the GP’s record.
- The GP’s list only details what the GP intends the patient to take and may not reflect what the patient is actually taking.
GP referral letter
GPs sometimes send referral letters when referring patients to emergency departments. However, the information about patients’ medicines can be of variable quality.
Computer-generated printouts, detailing both acute and repeat medicines and their issue dates, are usually more reliable than hand-written ones.
Previous discharge prescriptions
If a patient has been discharged from hospital recently, the discharge prescription filed in the case notes may be useful. However, it is advisable to check whether the patient is aware of any changes that have been made between the previous discharge and the current admission.
Care home records
A medicines administration record will often accompany a patient admitted from a nursing home. These should be read carefully to identify any medicines recently discontinued, refused or omitted.
GPs may not have information about medicines they are not required to prescribe. The patient’s medical history may suggest that he or she receives medicines via another prescriber, eg, chemotherapy from an oncologist, donepezil from a memory clinic for dementia or methadone from a community drug service.
Community psychiatric nurses may be a reliable source for information on the doses of antipsychotic depot injections.
Many patients use the same pharmacy for their regular medicines, although they are not required to do so. Community pharmacies may be able to give information when other sources are unavailable, eg, methadone doses when the community drug service is closed at weekends.
How many sources?
Because no information source is 100 per cent accurate, it is often necessary to use more than one source. Nonetheless, sometimes one source is sufficient, eg, it would be unnecessary to contact a GP surgery when an otherwise healthy patient says they do not take any medicines.
The age of the patient should not be a criterion for contacting a GP surgery — older patients may well be able to discuss the medicines that they have brought into hospital with them, even if they cannot remember every detail when questioned.
As practitioners become more experienced at taking medication histories, their intuition will inform them when additional sources should be used.
Using the information obtained
Once a pharmacist or pharmacy technician has obtained what he or she is confident is an accurate medication history, this information should be documented in the patient’s medical notes and the medical team should be informed if any changes to the inpatient prescription are required.
An initial clinical review of the patient should take place before contacting the medical team to ascertain whether the medicines, formulations and doses prescribed before admission are still suitable for the patient.
As an example, it would be considered negligent to request the prescribing of a patient’s aspirin if he or she had been admitted because of haematemesis.
Gareth Nickless is lead clinical liaison tutor/practitioner and Helena Noble is lead admissions pharmacist, both at Wirral University Teaching Hospital NHS Foundation Trust
1 Badowski SA, Rosenbloom D, Dawson PH. Clinical importance of pharmacist-obtained medication histories using a validated questionnaire. American Journal of Hospital Pharmacy 1984;41:731–2.
2 Einarson TR. Drug related hospital admissions. Annals of Pharmacotherapy 1993;27:832–40.
Citation: Clinical Pharmacist URI: 10044947
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