Action 4.10

Conduct evidence-based medication reviews

Ensure that medication reviews are conducted or supervised by a clinician with the appropriate skills and expertise, acting as part of a multidisciplinary team.¹ In large health service organisations, pharmacists may be the main provider of medication review services (often referred to as a clinical pharmacy service).² Although medication review is considered an inherent role of a pharmacist, medicines should also be reviewed by clinicians whenever decisions are being made about prescribing, dispensing and administering medicines.

For each medicine being reviewed, consider the clarity, validity and appropriateness of the medicine order, as well as the expected treatment outcomes. A patient’s experience of using medicines and their needs may change over time, especially during an admission to a health service organisation. This means that medicines may be reviewed more than once during an episode of care.

Use medication reviews to understand the patient’s experience with their current medicines and any newly prescribed medicines, and ensure that their medicine use is as safe as possible. This might include discussion of:

• When, how and whether the patient has been taking their prescribed medicines before admission to the health service organisation
• The patient’s satisfaction with the outcomes from their medicines (including those newly prescribed), as well as a positive care experience – for example, no avoidable medicine-related problems³
• The patient’s quality of life and life expectancy (for patients with long-term conditions).

Medication review should include assessment of current (existing and newly prescribed) medicines; the history of all medicine-related orders and administration records, including oral and parenteral, and multiple- and single-dose medicines; anaesthetic and operative records; and ceased medicine orders.

When conducting a medication review, consider the following:

• Is there a documented reason or evidence base for use of a medicine?
• Does the patient still need the medicine?
• Is the medicine still working?
• What risks are associated with use of the medicine, and what monitoring is required?
• Are there any patient-specific issues that will affect use of the medicine?

Guidance on conducting structured medication review includes:

• Society of Hospital Pharmacists of Australia Quick Guide: Assessment of current medication management
• National Institute for Health and Care Excellence Medicines Optimisation: The safe and effective use of medicines to enable the best possible outcomes
• National Prescribing Centre A Guide to Medication Review 2008.
• Clinical Excellence Commission. A Guide to Medication Reviews for NSW Health Services

Assess individual patient risk

Review the organisation’s risk assessment criteria for patients admitted who might be at risk of a medicine-related adverse event. Include consideration of the patient’s capacity to understand the risks of medicine use and make decisions about their medicines, and the need to involve carers or interpreters.

Assessment criteria for patients will depend on the patient casemix and services delivered by the organisation. For example, priority might need to be given to patients with a higher risk of experiencing a medicine-related adverse event.

Ensure that these criteria target patients who are most at risk, such as patients who:

• Are admitted as a result of a medicine-related problem
• Are taking multiple medicines or high-risk medicines
• Are taking medicines prescribed by multiple clinicians
• Have known or suspected adherence problems
• Have a chronic disease
• Have, or potentially have, a disability or impairment (for example, cognitive impairment)
• Are over 65 years old
• Have known allergies or ADRs.

Monitor the effectiveness of the organisation’s risk assessment tool(s) by conducting audits using indicators.

Guidance for developing medicine-related risk assessment criteria includes:

• Society of Hospital Pharmacists of Australia’s fact sheet Risk Factors for Medication-Related Problems
• National Prescribing Centre’s A Guide to Medication Review 2008 (page 33).

Set up processes to set priorities for, and document, medication reviews

For medication review to be effective, health service organisations need to have a formal, structured process in place for medication review that is conducted in partnership with the patient, carer or family member, and in collaboration with relevant clinicians involved in the patient’s care. Processes will depend on the infrastructure and resources available. A structured medication review will minimise medicine-related problems and optimise patients’ therapeutic outcomes. Electronic medication management with integrated clinical decision support is useful in screening for at-risk patients (for example, those with medicine-related problems).

Review organisational policies, procedures and guidelines to ensure that they outline:

• When a medication review is warranted
• The roles and responsibilities of clinicians in the process
• Training requirements for clinicians responsible for medication review
• Involvement of patients and carers (see Action 4.3 and the Partnering with Consumers Standard)
• Documentation requirements for recommendations or requests as a result of the medication review, and any subsequent action taken
• The role of electronic medication management, if available, in integrated clinical decision support
• How trends in medicine-related problems within the health service organisation are monitored
• Discharge referral processes for those patients who did not receive a medication review while in the health service organisation (for example, refer to residential medication management review, home medicines review or non-admitted clinical pharmacy review; see the Independent Health and Aged Care Pricing Authority website for definitions).

Review risk assessment criteria for patients admitted to the health service organisation who might benefit from a structured medication review. Ensure that priority is given to patients with a higher risk of experiencing medicine-related problems or adverse drug events.

Guidance on developing risk assessment criteria includes the Society of Hospital Pharmacists of Australia’s fact sheet Risk Factors for Medication-Related Problems.

Use quality improvement methodology to monitor and implement change. This can be achieved by auditing and evaluating medication review processes using national, state or territory, or local indicators. Use validated indicators such as the National Quality Use of Medicines Indicators for Australian Hospitals (indicators 1.5 and 6.2).

Conduct evidence-based medication reviews

Ensure that medication reviews are conducted or supervised by a clinician with the appropriate skills and expertise, acting as part of a multidisciplinary team.¹ In large health service organisations, pharmacists may be the main provider of medication review services (often referred to as a clinical pharmacy service).² Although medication review is considered an inherent role of a pharmacist, medicines should also be reviewed by clinicians whenever decisions are being made about prescribing, dispensing and administering medicines.

A patient’s experience of using medicines and their medicines needs may change over time, especially given that a patient admitted or presenting to a day procedure service is likely to be prescribed and administered a range of new medicines during an episode of care. This may necessitate the need for a medication review in circumstances such as:

• When decisions are being made to cease medicines before surgery, including which medicines would be appropriate and suitable to continue
• Ceasing or deprescribing a medicine post-procedure, as part of the intended outcome of treatment
• Following an adverse event or reaction while undergoing care
• When targeting specific high-risk categories of patients (for example, those on high-risk medicines, of certain ages, and with particular disease states or conditions).

Use medication reviews to understand the patient’s experience with their current medicines and any newly prescribed medicines, and ensure that their medicine use is as safe as possible. This might include discussion of:

• When, how and whether the patient has been taking their prescribed medicines before admission to the health service organisation
• The patient’s satisfaction with the outcomes from their medicines (including those newly prescribed), as well as their care experience – for example, no avoidable medicine-related problems⁴
• The patient’s quality of life and life expectancy (for patients with long-term conditions).

Medication review should include assessment of current (existing and newly prescribed) medicines; the history of all medicine-related orders and administration records, including oral and parenteral, and multiple- and single-dose medicines; anaesthetic and operative records; and ceased medicine orders.

When conducting a medication review, consider the following:

• Is there a documented reason or evidence base for use of a medicine?
• Does the patient still need the medicine?
• Is the medicine still working?
• What risks are associated with use of the medicine, and what monitoring is required?
• Are there any patient-specific issues that will affect use of the medicine?

Guidance on conducting structured medication review includes:

• Society of Hospital Pharmacists of Australia Quick Guide: Assessment of current medication management
• National Institute for Health and Care Excellence Medicines Optimisation: The safe and effective use of medicines to enable the best possible outcomes
• National Prescribing Centre A Guide to Medication Review 2008.
• Clinical Excellence Commission. A Guide to Medication Reviews for NSW Health Services

Assess individual patient risk

Review the organisation’s risk assessment criteria for patients admitted who might be at risk of a medicine-related adverse event. Include consideration of the patient’s capacity to understand the risks of medicine use and make decisions about their medicines, and the need to involve carers or interpreters.

Assessment criteria for patients will depend on the patient casemix and services delivered by the organisation. For example, priority might need to be given to patients with a higher risk of experiencing a medicine-related adverse event.

Ensure that these criteria target patients who are most at risk, such as patients who:

• Are admitted as a result of a medicine-related problem
• Are taking multiple medicines or high-risk medicines
• Are taking medicines prescribed by multiple clinicians
• Have known or suspected adherence problems
• Have a chronic disease
• Have, or potentially have, a disability or impairment (for example, cognitive impairment)
• Are over 65 years old
• Have known allergies or ADRs.

Monitor the effectiveness of the organisation’s risk assessment tool(s) by conducting audits using indicators.

Guidance for developing medicine-related risk assessment criteria includes:

• Society of Hospital Pharmacists of Australia’s fact sheet Risk Factors for Medication-Related Problems
• National Prescribing Centre A Guide to Medication Review 2008 (page 33).

Set up processes to set priorities for, and document, medication reviews

For medication review to be effective, health service organisations need to have a formal, structured process in place for medication review that is conducted in partnership with the patient, carer or family member, and in collaboration with relevant clinicians involved in the patient’s care. Processes will depend on the infrastructure and resources available. A structured medication review will minimise medicine-related problems and optimise patients’ therapeutic outcomes. Electronic medication management with integrated clinical decision support is useful in screening for at-risk patients (for example, those with medicine-related problems).

To ensure that patients admitted to a day procedure service will benefit from a medication review, review the existing policies, procedures and guidelines of the day procedure service, network or group to include the range of circumstances when patients would ideally receive a medication review. This may be part of the pre-admission process conducted by the patient’s specialist clinician or anaesthetist.

Review organisational policies, procedures and guidelines to ensure that they outline:

• When a medication review is warranted
• The roles and responsibilities of clinicians in the process
• Training requirements for clinicians responsible for medication review
• Involvement of patients and carers (see Action 4.3 and the Partnering with Consumers Standard)
• Documentation requirements for recommendations or requests as a result of the medication review, and any subsequent action taken
• The role of electronic medication management, if available, in integrated clinical decision support
• How trends in medicine-related problems within the health service organisation are monitored
• Discharge referral processes for patients who did not receive a medication review while in the health service organisation (for example, refer to residential medication management review, home medicines review or non-admitted clinical pharmacy review; see the Independent Hospital Pricing Authority website for definitions).

Review risk assessment criteria for patients admitted to the health service organisation who might benefit from a structured medication review. Ensure that priority is given to patients with a higher risk of experiencing medicine-related problems or adverse drug events.

Assessment criteria for patients will depend on the patient casemix and services delivered by the organisation (see Action 4.11).

Guidance on developing risk assessment criteria includes the Society of Hospital Pharmacists of Australia’s fact sheet Risk Factors for Medication-Related Problems.

Use quality improvement methodology to monitor and implement change. This can be achieved by auditing and evaluating medication review processes using national, state or territory, or local indicators. Use validated indicators such as the National Quality Use of Medicines Indicators for Australian Hospitals (indicators 1.5 and 6.2).

Examples of evidence

Select only examples currently in use:

• Policy documents about undertaking, prioritising and documenting medication reviews
• Documented examples of actions taken as a result of medication review
• Orientation or training documents about medication review
• Employment documents that outline the roles, responsibilities and accountabilities for medication review
• Audit results of compliance with the system for medication review.

Conduct evidence-based medication reviews

Ensure that medication reviews are conducted or supervised by a clinician with the appropriate skills and expertise, acting as part of a multidisciplinary team.¹

If necessary, approach a nearby larger hospital or local community pharmacy involved with the supply of medicines for advice or expertise regarding medication review, and confirm their role and responsibility in this process. For instance, the local community pharmacy would be expected to conduct some form of medication review at the time of supply or dispensing for patients within MPSs or small hospitals. This service could also be provided using a telehealth approach.

Although medication review is considered an inherent role of a pharmacist, medicines should also be reviewed by clinicians whenever decisions are being made about the prescribing, dispensing and administration of medicines.

Medication review should include the assessment of current (existing and newly prescribed) medicines; the history of all medicine-related orders and administration records, including oral and parenteral, and multiple- and single-dose medicines; anaesthetic and operative records; and ceased medicine orders.

When conducting a medication review, consider the following:

• Is there a documented reason or evidence base for use of a medicine?
• Does the patient still need the medicine?
• Is the medicine still working?
• What risks are associated with use of the medicine, and what monitoring is required?
• Are there any patient-specific issues that will affect use of the medicine?

Guidance on conducting structured medication review includes:

• Society of Hospital Pharmacists of Australia Quick Guide: Assessment of current medication management
• National Institute for Health and Care Excellence Medicines Optimisation: The safe and effective use of medicines to enable the best possible outcomes
• National Prescribing Centre A Guide to Medication Review 2008.
• Clinical Excellence Commission. A Guide to Medication Reviews for NSW Health Services

Set up processes to set priorities for, and document, medication reviews

Review organisational policies, procedures and guidelines to ensure that they outline:

• When a medication review is warranted
• The roles and responsibilities of clinicians in the process
• Training requirements for clinicians responsible for medication review
• Involvement of patients and carers (see Action 4.3 and the Partnering with Consumers Standard)
• Documentation requirements for recommendations or requests as a result of the medication review, and any subsequent action taken
• The role of electronic medication management, if available, in integrated clinical decision support
• How trends in medicine-related problems within the health service organisation are monitored
• Discharge referral processes for patients who did not receive a medication review while in the health service organisation (for example, refer to residential medication management review, home medicines review or non-admitted clinical pharmacy review; see the Independent Hospital Pricing Authority website for definitions).

Review risk assessment criteria for patients admitted to the health service organisation who might benefit from a structured medication review. Ensure that priority is given to patients with a higher risk of experiencing medicine-related problems or adverse drug events.

Assessment criteria for patients will vary depending on the patient casemix and services delivered by the organisation (see Action 4.11).

Guidance on developing risk assessment criteria includes the Society of Hospital Pharmacists of Australia’s fact sheet Risk Factors for Medication-Related Problems.

Use quality improvement methodology to monitor and implement change. This can be achieved by auditing and evaluating medication review processes using national, state or territory, or local indicators. Use validated indicators such as the National Quality Use of Medicines Indicators for Australian Hospitals (indicators 1.5 and 6.2).