Optimising medication use

Medication safety is improved and errors decrease significantly when strategies are put in place to increase the accuracy of medication history taking and medication reconciliation¹.

There are several things we can do to support an effective and easy to manage medication regime for older people while they are in hospital.

Document medication information

Keep detailed records of medication to monitor for changes to the older person's baseline Best Possible Medication History (BPMH).

The records should include:

• BPMH
• medication reconciliation
• key information about each medicine (drug name, dose, form, frequency, duration)
• patient compliance/adherence issues
• support for managing medications, for example carer and family help the patient manage medicines; the patient collects medicines in a medicopak/webster pack from community pharmacy
• risk factors
• medicines recently ceased
• allergies and adverse drug reactions
• plans to continue, cease or change medicines during the patient’s episode of care, which can be used to inform the discharge summary and prescriptions at time of discharge.

Medication information tools

The following tools for documenting and sharing medication information can be used to reduce prescribing, dispensing and administration errors.

• Medication Management Plan (MMP) – use this standardised form to ensure complete and accurate documentation of medication information on admission and throughout the episode of care².

• National Inpatient Medication Chart (NIMC) - is an evidence-based, best practice suite of nationally standard medication charts. The NIMC enables information to be communicated consistently between health professionals³. Use of the NIMC is a mandatory requirement for health service organisations seeking accreditation against NSQHS Standard 4.

Deprescribing

Deprescribing is reducing the dosage or discontinuing a medication with the aim of reducing the risks associated with polypharmacy and improving quality of life⁴.

Talk to the patient, the doctor and pharmacist about the possible benefits of deprescribing and consider it after a thorough medication review when⁵:

• there is a risk of polypharmacy
• the patient is experiencing adverse drug reactions
• the treatment has been ineffective
• the patient has experienced a fall
• the patient's treatment goals have changed.

Approach deprescribing with caution, as there are both risks and benefits. Focus on improving quality of life, reducing risks and alleviating symptoms. Ensure that this is a shared decision with the patient⁴.

When considering deprescribing, the nursing, medical and pharmacy teams will:

• weigh up the benefits with the potential adverse consequences
• target patients with highest Adverse Drug Event risk
• target non-beneficial medications
• target drugs known to do harm or are inappropriate
• set a discontinuation regime and ongoing evaluation (ideally with the same clinician)
• set shared goals with the patients and provide education, as it can be daunting for patients and families to discontinue medications they have been taking for many years.

Balance the risks and benefits of medications

Medication use in older people involves balancing disease management with avoiding adverse events.

Discuss the risks and benefits of each treatment with the patient.

Consider how treatments may affect the patient’s care goals, such as maintaining physical function and independence.

Consider how medications may impact on the person’s quality of life.

1. McLeod, S. E., Lum, E., Mitchell, C. Value of Medication Reconciliation in Reducing Medication Errors on Admission to Hospital, Journal of Pharmacy Practice and Research 2008. 38: p. 196.

2. Australian Commission on Safety and Quality in Health Care (ACSQHC), National medication management plan user guide 2009: ACSQHC, Sydney.

3. Australian Commission on Safety and Quality in Health Care (ACSQHC), National inpatient medication chart user guide 2009: ACSQHC, Sydney.

4. Scott, I. A., Anderson, A., Freeman, C. R, Stowasser, D. A. First do no harm: a real need to deprescribe in older patients. The Medical Journal of Australia 2014, 201: pp. 390-92.

5. Le Couteur, D., Banks, E., Gnjidic, D., McLachlan, A. Deprescribing. Australian Prescriber 2011. 34.