Shared learning database

Type and Title of Submission


Medicines Reconciliation at South London Healthcare Trust


The aim of medicines reconciliation on hospital admission is to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission. Details to be recorded include the name of the medicine (s), dosage, frequency, and route of administration. A retrospective audit was carried out to ensure that medicines reconciliation was carried out correctly, and to determine if unintentional discrepancies identified during the MR process were successfully resolved.

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:

PSG001 - Technical patient safety solutions for medicines reconciliation on admission of adults to hospital

Is the submission industry-sponsored in any way?


Description of submission

Aims and objectives

Audit to ensure delivery of level 2 Medicines Reconciliation across SLHT was in line with the newly developed policy covered all Trust sites.


In 2011 a CQUIN target for medicines reconciliation for SLHT was agreed. If a minimum of 60% of patients received a level 2 pharmacy led MR within 24 hours, the Trust would receive income of 60,000.

In 2007 NICE recommended that all healthcare organisations should have policies in place for medicines reconciliation on admission and that pharmacists should be involved as soon possible, ideally within 24 hours.

At SLHT level 2 pharmacy led MR is provided to all ward areas except day case patients and patients in the maternity units. This is in line with other Trusts in London and South East London. An audit carried out in 2010 demonstrated that level 2 MR was not generally offered to maternity units. Day case patients do not receive level 2 pharmacy led MR since length of stay is usually less than 24 hours. At SLHT patients on two day case units who are in hospital, or expected to be in hospital, for > 24 hours receive a pharmacy led level 2 MR. Data from these patient groups was included in the audit.

Currently level 2 pharmacy led MR is not provided at weekends because of a lack of pharmacy staff to deliver this service, and lack of availability of information from GP services to support delivery of MR at weekends.

An audit carried out at SLHT in 2010 identified that while the legacy sites at SLHT had site specific Medicines Reconciliation Policies, that a single policy across SLHT was needed.


The East and South East of England Specialist Pharmacy Services developed a template document which was used for the development of a single policy across SLHT. A key element of the new policy was the inclusion of tools to support MR on the wards. A checklist to support the MR process was included. This tool could be used by both pharmacy and medical staff during the MR process. A second, more detailed tool, was also developed specifically to support pharmacy staff undertaking MR. This included specific questions relating to high risk drugs eg warfarin. Patient surveys at SLHT have indicated that some patients are not satisfied with the information received about the side effects of the medicine they take. For this reason the tool also includes questions for the pharmacist to ask if they require further counselling in relation to any aspect of their medication. The tools are included as appendices so that they can be printed and taken to the ward and act as an aide memoire. The policy includes information on communication for patients with communication difficulties. The policy was approved in December 2011 and training provided across SLHT to all staff to ensure delivery of level 2 MR was in line with the new policy. The audit was carried out on all wards at SLHT (except maternities and day care) on Thursday 23rd February 2012.

Patients admitted after 6pm on Wednesday 22nd February were excluded. On admission wards, patients admitted before midday on Thursday 23rd February were included. Data was collected on patients admitted over a weekend. (Friday night or Saturday all day).

Data was collected on the number of inpatients, timescale for delivery of level 2 MR, the number and type of unintentional discrepancies, and resolution of these discrepancies.
1. A minimum of 60% of inpatients received a level 2 pharmacy led MR within 24 hours of admission.
2. 100% of unintentional discrepancies were resolved.

Results and evaluation

Level 2 pharmacy led MR is delivered to 70.07% of inpatients at SLHT within 24 hours of admission. If patients admitted to SLHT on a Friday night or a Saturday are excluded then the % of patients receiving a level 2 pharmacy led MR rises to 84.1%. This is in line with NICE/NPSA recommendations.

951 unintentional discrepancies were identified (1.1 unintentional discrepancies per medicines reconciliation). 73% of these were resolved at the time of the audit.

For further details of the results of this audit please refer to the summary paper in the supporting material.

Key learning points

In order to achieve the CQUIN target it was important to have a policy in place, and to ensure staff were aware of the policy and engaged with the process. Training was carried out on all sites and staff regularly reminded of the importance of complying with the policy and achieving the CQUIN target. An audit on three sites is a challenge. In order to ensure that data was collected in the same way an audit lead was appointed on all sites. All staff were briefed and given written information on how to undertake the audit. The audit tool had been used in 2010 and modified to make data entry as simple as possible. All site leads were asked to complete the data set for their site which also ensured that they quality checked the data provided.

Implementation of MR is a key patient safety initiative. Involvement of pharmacists in MR was examined in one randomised controlled trial (RCT), two before-and-after trials, and five observational studies. The RCT reported that the number of discrepancies between hospital and home medication fell after pharmacist involvement compared with standard care (nurse-conducted history and surgeon-generated orders). The number of discrepancies fell from 44 per 100 patients (68/154) to 19 per 100 patients (30/154).

On admission to SLHT all patients are clerked in by a doctor, a medication history taken, and a drug chart completed. This audit was carried out after medical clerking, and therefore all unintentional discrepancies identified during pharmacy led MR were identified following medical clerking. A total of 1.1 unintentional discrepancies per MR were identified. This clearly demonstrates that pharmacists are more likely to identify and resolve unintentional discrepancies between what the patient is prescribed during their admission, and the drugs prescribed at home than medical staff. For more learning points please click here.

View the supporting material

Contact Details

Name:Sinead O'Halloran
Job Title:Associate Chief Pharmacist Clinical Services
Organisation:South London Healthcare NHS Trust
Address:Queen Elizabeth Woolwich, Stadium Road
Postcode:SE18 4QH


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This page was last updated: 09 July 2012

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