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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

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Medication History Taking and confirming and reconciling medication on admission

Ian Coombes

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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

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Understand pathophysiology, pharmacology, pharmacokinetics, EBM.

Understand multiple pathologies, other pharmacologies, appreciate consequences of errors, safe practice

Personal views, experiences, seen other patients, read literature

Knowledge of BNF, hospital formulary, pharmacology, EBM

Safe drug therapy

Effective drug therapy

Aimsof Pharmaceutical Care

Economic drug therapy

Improve quality of life

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Problem solving

Interpreting data

Gathering data

Providing a solution

Consultation Skills

Monitoring outcomes


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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

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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% ofpatients 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)

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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

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What sort of things are going through the mind of Mrs CCF at the moment?

  • Fear of the disease

  • I’ve got heart failure, it must be the end of the line, I’m going to die in this horrible hospital

  • If I survive this, how am I gong to cope in future? My family and friends are going to get sick of me, I may as well give up now

  • Fear of future disease management

  • I’m going to have to take medicines for the rest of my life aren’t I, what if I forget?

  • I saw something on the news last week about antidepressants, are all the medicines they prescribe going to kill me?

  • Trust healthcare professionals

  • I’ve heard horrible stories about these places, people going in fit and well, and coming out in boxes

  • What about Shipman, are they all after my money?

  • Other anxieties

  • Oh no, I have an appointment at the eye clinic on Monday, they’re going to be expecting me, I’ll never get another appointment

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By focusing care on the patient the moment?

  • 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

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General points for good consultation about medicines the moment?

  • 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

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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 involve?

  • 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 involve?

  • 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

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Confirming Medication History involve?

  • 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)

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Benefits/ limitations of own medication involve?


  • 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


  • 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

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Video involve?Medication History Interview 1


  • 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

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Key Messages from 2 involve?nd 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

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Medication History involve?

  • 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 actuallytaking 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?

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Information Obtained – interview 1 involve?

How does this compare to the next video?…

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Don’t Forget involve?

  • 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

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Taking the history is first step involve?

  • Now we need to link it to the patient!

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Adding Value after taking the history involve?

  • Matching medications with diagnoses

  • Are the medications appropriate?

  • Are the medications achieving what is expected?

    • Is the diagnosis correct?

    • Is the indication appropriate?

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Why Reconcile Medication? involve?

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 re-admission in 30 days (Stowasser, JPPR 2002)

- The Joint Commission of Accreditation of Healthcare Organisations (JCAHO)’s Sentinel Event Database (2006)

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Admission involve?


Med Reconciliation

Med Review

Med Reconciliation

Clinical Handover

Clinical Handover

Clinical Handover

Clinical Handover

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Lessons to Learn involve?

  • 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 involve?

NO ß-blocker


Left Ventricular Failure


NO ACE Inhibitor


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Reconciliation of Medications involve?

NO oral hypoglycaemics

NO Insulin


NO ACE Inhibitor


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Precipitation of Admission? involve?

Nitrate Tolerance


Acute Renal Failure

Left Ventricular Failure

Low hydralazine

NO ß-blocker


?BP Controlled amlodipine dose

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Adherence involve?

Question the patient on concordance/non-compliance 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?”

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Risks v Benefits of Treatment involve?(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

  • Patients’ actions might not correspond to treatment recommendations (e.g. taking less)



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Medication Management involve?

Assess patient’s ability to manage own medicines

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Key Issues for Practice involve?

  • 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

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Summary involve?

  • 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, immuno-suppressive therapy, lack of concordance

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Any Questions? involve?