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Medicines Reconciliation in children

The clinical significance of medicines reconciliation (MR) in children admitted to hospital: development and evaluation of pharmacy led admission services.

The problem

Medicines reconciliation is a process to ensure that accurate and up-to-date medicines information, relating to a single patient, is communicated appropriately as the patient moves between different care providers. Without medicines reconciliation (MR) there is evidence that medication processes on admission to hospital are sub-optimal. As a consequence NICE provided guidance in 2007 to direct hospitals to introduce a pharmacy led reconciliation service. However, NICE guidance excluded children under the age of 16 based on the lack of evidence concerning MR in this important patient cohort.

Aims

The aims of this study were: 1. To identify and consider: a) existing studies reporting medication discrepancies occurring at transitions in care for children and b) studies that report medicines reconciliation interventions in children. 2. To investigate the occurrence and prevalence of medication discrepancies and possible clinical implications relating to hospitalised children in a wider study cohort that may be possible to generalise. 3. Identify how medicines reconciliation in children should be conducted and its implications for pharmacy practice.

Making the case for change

A literature review found very few relevant paediatric studies (1 in the UK). The UK study showed there was a high level of medicine discrepancies in children without MR, but the data was limited to one speciality in one centre. Our study of MR on admission to hospital for children was conducted in four hospital centres in England and across a wide range of clinical specialities. Clinical pharmacists conducted thorough medication reviews and medicines reconciliation was conducted. The final reconciliation was reviewed against all the sources used to obtain the review and the following indicates which sources the information agreed with the final reconciliation: parent-carers were 81%; GPs 70% and PODs 54%. There were 33% of medication discrepancies between the original doctors prescription in the hospital and the final chart post reconciliation (excluding changes made on admission due to the patient’s admitting clinical condition) arising from 64% of study patients. The clinical significance of the discrepancies was defined as moderate or severe in 2/3rd of occasions. During analysis it was identified that common omissions from the GP and parent’s records were chronic medicines used intermittently or in an emergency such as inhalers, or medicines for seizure control.

Your improvement

This data has been shared with the Neonatal & Paediatric Pharmacists Group and the publications are awaiting approval. The study has shown that it is just as important to doing medicines reconciliation when children come into hospital. Due to the more complex dosing schedules, changes in formulation and use of unlicensed medicines it is probably more important to ensure reconciliation is completed. This study was part of a PhD and conducted with academic rigour and the findings have helped ensure that paediatrics have been included in the latest NICE review of reconciliation within the Medicines Optimisation submission.

Learning and next steps

Medicines Reconciliation is a changing issue as electronic prescibing and sharing of records becomes more common. However admission to hospital should be seen as a chance to do a medicines review in children, to pick up on issues such as 'are they up to date with vaccinations, do their parents smoke and can they be helped to stop, can they now take tablets?' Thus, the need for reconciliation is proven but the interaction around it can count for so much more.

Quality assurance/MHRA Registration

NICE have now accepted that all children (as well as adults) should have medicines reconciliation conducted when a child is admitted to hospital.