Shared learning database

Type and Title of Submission


Medicines Reconciliation


This project will reduce medication errors and in the extreme prevent deaths - safety. This project will allow service users to be prescribed correct medication at the point of admission or to have their medication reviewed at that time and ensure they are prescribed effective treatment in a timely manner to aid recovery and thus shorten their length of stay - effectiveness. In line with above, to have effective treatment and consequently alleviate symptoms in a timely fashion will increase the service user experience. Being in hospital for a shorter time as possible will add to an increase in quality of experience for the service user - patient experience.



Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

Pt safety Guidance 1 - Technical patient safety solutions for medicines reconciliation on admission of adults to hospital

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?


Description of submission


Reduce medicines related harm at the point of admission through implementation of NICE Patient Safety Guidance.


1. Raise awareness within the Multidisciplinary team of the potential for medication errors on admission to hospital. 2. Develop and agreed Trust wide documentation to ensure medicines reconciliation occurs as part of the admission process. 3. Refine documentation through a pilot project prior to Trust wide use.


Evidence exists to show that medication errors on admission to hospital are preventable by ensuring that medicines are reconciled with 24 hrs of admission. The Trust was already working on two admissions pathways within older people and general adult wards, the publication of the NICE Patient Safety Guidance provided the stimulus to pull together a Trust wide care pathway to be used in all areas of the Trust. A steering group was formed to coordinate the production of the medication history data collection documentation (as part of the pathway). A pilot of the documentation was conducted on four wards. An audit of this took place October - December 2008, following which the documentation was revised in light of the findings. The Trust also utilised membership of the Prescribing Observatory Mental Health (POMH UK) through their Topic 8 Medicines Reconciliation audit in order to establish the Trusts baseline position. Following a campaign to raise awareness amongst clinicians the documentation was launched for use throughout the Trust on the 1st August 2009.


1. Insufficient Pharmacists to undertake Medicines Reconciliation was identified, are proforma was devised to enable other members of the multi disciplinary team to undertake the task in the absence of specialist pharmacists at the point of admission.

Results and evaluation

Using Prescribing Observatory Mental Health benchmarking we anticipate a further audit will show the benefit of this system (results anticipated Autumn 2010).

Key learning points

Clear leadership of steering group, lead by the Trust's Chief Pharmacist, guided and maintained focus of the project Multi disciplinary involvement is key throughout the process. Membership of POMH UK enabled both within and across mental health trusts comparisons. Use of a clear proforma to guide staff through the process of medicines reconciliation. Clear communication - disseminating to stakeholders through a variety of channels, including: Medicines Management Committee, Consultant, Directorate management and governance meetings and the Trust's newsletter.

View the supporting material

Contact Details

Name:Helen Oldknow
Job Title:Effectiveness lead
Organisation:Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust
Address:St Catherine's
County:South Yorkshire
Postcode:DN4 8QN
Phone:01302 796726
Fax:01302 796726


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This page was last updated: 30 September 2009

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Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.