Pharmacy + Admissions Unit = > Safety?

Kieron Power, Lead Pharmacist for Elderly Care

Abertawe Bro Morgannwg University Health Board


Medicines reconciliation (MR) is defined by NICE as “the process of identifying the most accurate list of a patient’s current medication and comparing it with the list currently in use, recognising any discrepancies, and documenting any changes, thus resulting in a complete list of medications accurately communicated”. The absence of this process when patients are transferred between care settings can lead to medication errors and omissions, and potential harm.

While MR is the responsibility of all healthcare professionals involved in medicines management, in practice it is pharmacists who generally undertake this role in a hospital setting; collecting a medication history from a variety of sources, checking this against the drug chart written by a doctor on admission and communicating any discrepancies to the prescriber for action. MR has always been a retrospective process, undertaken after the prescriber has completed the clerking. NICE recommend that medicines reconciliation must be completed within 24 hours of a patient being admitted. Baseline data from the Singleton Admission Unit (SAU) identified a 45% error rate and 15 hours mean time to reconciliation (Table 1). During the window from admission to reconciliation, a patient is at a higher risk of potential harm due to medication error or omission.

Our challenge was to re-engineer pharmacy services on an admissions unit to reduce these risks.


We have:

  • Trained more pharmacy technician staff in drug history taking and medicines reconciliation;

  • Repositioned the pharmacy team (a pharmacist and technician) to the start of the admissions process, to undertake prospective medicines reconciliation;

  • Extended the time the pharmacy team spend inthe admissions unit from 9am to 11am to 9am to 8pm; and,

  • Had agreement that pharmacist write drug charts prior to doctor seeing patient, which the doctors sign after clerking the patient.


  • For almost 70% of admissions via SAU, the pharmacy team are first healthcare professionals to have contact with the patient. Prospective MR is performed for these patients;

  • Compared to baseline data the mean time for MR for all patients admitted via SAU fallen from 15 hours to 3.5 hours (see the table below);

  • There has been a considerable reduction in patients who leave the admission ward without MR performed (33% to 6%); and,

  • Pharmacist transcribing onto drug charts following prospective reconciliation has reduced prescribing error rate from above 40% to 2.6% (see the table below).


There is no recommendation as to where MR should be performed in an acute care setting, only that it should be performed within 24 hours of admission, at the point where patients’ healthcare needs are at their greatest.

This project demonstrates that prospective MR at the point of admission reduces risk with regard to medicines error or omission, improving patient safety, and reduces harm. Through an effective training programme and standardised process, there is a reduction in inappropriate variation. Patients are given the opportunity to discuss their medication, allowing them to feel engaged with their medication.

Part of cohort Bevan Exemplar Projects 2016-17