Chapter 1: Medication Reconciliation

INTRODUCTION • take 5 or more medicines

Medication reconciliation is a formal process intended to • take more than 12 doses of medicines per day
prevent medication errors and medicines-related problems • take a medicine that requires therapeutic monitoring
at transition points in patient care. It is an essential element or is a high-risk medicine
of medication management. Medication reconciliation • have clinically significant changes to their medicines
should occur at all points of transition between episodes or treatment plan within the last 3 months
of care. Medication reconciliation is consistent with the • have suboptimal response to treatment with medicines
concept of continuity of medication management across • have difficulty managing their medicines because of
the continuum of care as required by the Guiding Principles literacy or language difficulties, dexterity problems,
to Achieve Continuity in Medication Management and impaired sight, confusion/dementia or other cognitive
includes Guiding principle 4: accurate medication history.1 difficulties
Failure to reconcile medications at transitions of • have impaired renal or hepatic function
care accounts for many preventable adverse events.2 • have problems using medication delivery devices or
Poor communication of medical information at points of require an adherence aid
transition was responsible for up to 50% of medication • are suspected or known to be non-adherent with their
errors and up to 20% of adverse medicine events.3 medicines
• have multiple prescribers for their medicines
OBJECTIVE AND DEFINITION • have been discharged within the last 4 weeks from
Objective or have had multiple admissions to a health service
The purpose of medication reconciliation is to ensure organisation.
patients receive all intended medicines and to avoid errors For patients who attend a health service organisation
of transcription, omission, duplication of therapy, and as a day patient or for ambulatory care (e.g. chemotherapy,
drug–drug and drug–disease interactions. The procedure renal dialysis, radiotherapy), medication reconciliation
for each organisation should be standardised. Ideally, should be completed at the first episode of care and then
the medication reconciliation process should commence every 6 to 12 months, following a recent admission or when
as soon as possible on presentation or admission and a there is a change in their treatment plan. See Figure 1.
documented, confirmed medicines list be available before
medicines are prescribed.

Definition
Medication reconciliation is the standardised process of
obtaining a patient’s best possible medication history
and comparing it to presentation, transfer or discharge
medication orders in the context of the patient’s medication
management plan (MMP).4-6 See Chapter 4: Medication
management plan.
Medication reconciliation also involves documenting
discrepancies identified between the medication history
and current medication orders and how these discrepancies
were resolved.

EXTENT AND OPERATION

Medication reconciliation should be undertaken on:4
• presentation or admission to a health service
organisation
• transfer between wards and care settings within an
organisation
• discharge or transfer from the health service
organisation to the community or other organisations Figure 1. Medication reconciliation pathway. 
• transfer between community-based providers.
All patients should have their medication reconciled Medication reconciliation is a four-step process and
as soon as possible after admission or presentation. See involves:
Figure 1. If medication reconciliation cannot be completed 1. obtaining and documenting the best possible
for all patients, prioritise patients most likely to obtain medication history
maximum benefit. Patients most at risk of medicines- 2. confirming the accuracy of the medication history
related problems include those who: 3. comparing the medication history with the prescribed
• have medication misadventure as the known or medicines and follow-up discrepancies
suspected reason for their presentation or admission 4. supplying verified information for ongoing care.
to the health service organisation
• are aged 65 years or older

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 Medication reconciliation requires an interdisciplinary Table 1.1. Background patient information
approach that includes doctors, nurses, pharmacists and The following information about the patient is useful:
patients/carers across the continuum of care.2 Although •age, consider the ability to metabolise or excrete medicines,
accurate medication histories are important for optimal and the implications for appropriate selection of medicine and
patient care, obtaining them can be complex and time dosage
consuming. Evidence suggests this task is poorly done •gender, consider impact of gender on medicine selection
by those not focused on medication management and
•height and weight
that pharmacists obtain more accurate medication
histories than other health professionals.7-10 Pharmacists •pregnancy or lactation status
have demonstrated that they are skilled and accurate •immunisation status
in undertaking this task, and is valued by doctors.7,11,12 •ethnic background or religion, consider implications for
Pharmacist-obtained medication histories have also medicine selection including pharmacogenetic factors
been shown to be more accurate than patient-completed •social background, consider the impact on patient’s ability to
medication histories.13 manage their medicines
Health service organisations need a reliable and robust
•details of regular GP, community pharmacy or other health
medication reconciliation process that clearly articulates professional as appropriate
the steps involved and who is responsible for each step.
•details of medication use, e.g. self-administering, nurse
administers from dose administration aid, medicines crushed
POLICY AND PROCEDURE
Obtain the Best Possible Medication History •ability to communicate, e.g. cognitive function, language barriers,
alertness, mental acuity, psychological state, and requirements
A medication history is a record of all the medicines for communication aids, e.g. glasses, hearing aids, need for
actually taken by the patient in the period before interpreter service
admission or presentation for the episode of care and
•ability to take medicines as prescribed, e.g. cognition, dexterity,
includes information about previous adverse drug swallowing ability
reactions (ADRs), adverse medicines events and allergies
•presenting condition, consider the possibility of adverse drug
and recently ceased or changed medicines.1 Obtaining a
reactions, poor adherence, inadequate dosing, inappropriate
best possible medication history involves: therapy as a contributor to hospital presentation/morbidity
• reviewing background information
•working diagnosis, consider appropriate evidence-based therapy
• conducting a patient/carer medication history
interview. •previous medical history, identify potential medicine and/or
disease contraindications and ensure that management of the
presenting complaint does not compromise a prior condition.
Review Background Information Consider therapies for prior conditions that may have been
Before conducting an interview, review known patient- omitted
specific information. Use appropriate sources for
•relevant laboratory or other findings (if available), focus on
background information, e.g. ward handover sheet, findings that will affect decisions regarding medicines, such as:
health records, transfer summaries, laboratory results, -renal function
other health professionals. Some information may not be -electrolytes
available from these sources and will need to be obtained -liver function
during the face-to-face interview. -full blood count
A combination of information sources can be used to -cardiac markers
-general observations
compile or confirm the medication history. Alternative -relevant previous therapeutic drug monitoring results.
sources of information must be used if the patient does not
Use appropriate sources to obtain information, such as:
manage their own medicines or if a reliable medication
history cannot be obtained from the patient/carer. •patient/carer
Reviewing background information before the face- •patient’s own medicines and/or medication list
to-face interview allows patients to be prioritised and •previous prescriptions (community pharmacy, discharge/
identifies issues to focus on during the interview. See outpatient)
Table 1.1. •preadmission clinic records
•GP referral letter/other correspondence, e.g. ambulance service
Conduct Patient/Carer Medication History Interview
notes
The critical component of obtaining a best possible
medication history is a structured face-to-face interview •GP medication list
with the patient/carer, preferably before admission, within •adherence aids
24 hours of presentation or admission, or at least before the •transfer information from another health service organisation,
end of the next working day after admission.1 Pharmacists e.g. nursing home, hospital, hostel
in the emergency department, medical assessment unit •electronic records, e.g. pharmacy dispensing system, discharge
or preadmission clinic are ideally placed to obtain a medication records
medication history on admission.14 •current medication chart/administration records.
Interviewing the patient/carer to obtain a medication
history is a key clinical activity performed by pharmacists. • use the information obtained to develop a MMP
Medication history interviews provide opportunities for • initiate plans for discharge and follow-up.
pharmacists to: The medication history checklist on the National
• establish rapport with the patient/carer and to explain Medication Management Plan is a useful tool to use during
their role in the patient's care the medication history interview.15 See Table 1.2.
• commence preliminary education regarding the
patient’s medicines and any changes to their medicines

Journal of Pharmacy Practice and Research Volume 43, No. 2 (suppl), 2013. S7
 Table 1.2 Detailed instructions for conducting a patient/carer medication history interview
The nature of the interview will depend on the patient. Determine the specific goals of the interview and tailor the questions and
discussion to obtain the necessary information. Questions must be relevant, as exhaustive interviews may be counter productive.
Conduct the interview in a location that allows privacy and minimises the risk of interruption and distraction. After determining the
ability of the patient to communicate, choose an appropriate location and adopt a suitable position to enable the interview to take place
comfortably and effectively.
1. Interview technique
•Greet patient and establish their identity.
•Ideally, use the AIDET framework:16 Acknowledge the patient by name; Introduce yourself by name and profession and tell the patient
how you can help them; tell them how long you will be talking to them (Duration); Explain what you are doing and Thank the patient at
the conclusion of the interview.
•Confirm that the time is convenient.
•Respect patient’s right to decline an interview.
•Identify and attempt to overcome any communication barriers.
•Establish rapport with patient to support ongoing communication.
•Explain purpose of the interview (other health professionals may have already performed a medication history, so it may be necessary to
explain the reason for a pharmacist-obtained medication history).
•Determine who is responsible for administering and managing the patient’s medicines at home.
•Use an appropriate interview manner, avoid appearing rushed, be polite, attentive, maintain eye contact, avoid interrupting the patient,
be non-judgemental, and communicate clearly and effectively. Use appropriate techniques, begin the medication history interview with
open-ended questions to encourage the patient to explain and elaborate and move to close-ended questions to systematically minimise
omissions. Use a structured and systematic approach to obtain a comprehensive medication history:
-ask patient/carer about their medicines using a logical and systematic method to ensure all relevant information is obtained and to avoid
omitting relevant details
-consider using a written/mental checklist to ensure all patients/carers are asked pertinent questions regarding the patient’s medicines.
-consider using the medication management plan to structure the interview and use as a guide to the information that is required.
2. Allergy and ADR history
•Confirm and document an accurate and comprehensive allergy and ADR history:
-confirm with patient/carer details of allergies or previous ADRs to any medicines (including CAM).
-if an allergy/ADR is known, document the medicine, reaction and date of reaction (if known) on the medication chart and any associated
document
-if patient reports no history of ADR/allergy, tick the ‘nil known’ box on the medication chart
-if the ADR history cannot be established, tick the ‘unknown’ box on the medication chart
-sign and date the entry and print your name
-follow institutional policy regarding documentation of allergy and ADR history in the patient’s health record.
3. Prescription and non-prescription medicines
•Ask patient/carer about their use of prescription and non-prescription medicines:
-ask which medicines were taken immediately prior to admission, specifically name (active ingredient and brand), dose, frequency and
duration of current therapy
-locate and review patient’s own medicines, if available, and consider appropriateness in view of current clinical details
-ask who is the usual prescriber for each medicine
-determine what they perceive the indications for each medicine are
-determine details of any adverse effects or allergies associated with current medicines
-determine the need for further supply of medicines on discharge
-ask about recently ceased/changed medicines and the reasons for the changes
-ask if they use adherence aids
-ask how they store their medicines at home
-ask if they use recreational substances, including alcohol, nicotine and illicit drugs, and the frequency of use.
•Ask patient/carer about their use of complementary and alternative medicines (CAMs):
-ask which CAM they are taking including herbal, vitamin and naturopathic medicines (specifically name, dose, frequency and duration of
current therapy).
-ask their reason for taking the CAM.
4. Adherence assessment
This will be an ongoing process during the episode of care and assists in developing a medication management plan, facilitating discharge
or transfer and ongoing care. See Chapter 4: Medication management plan and Chapter 6: Facilitating continuity of medication management on
transition between care settings.
•Undertake a structured adherence assessment including patient’s understanding and experience of taking their medicines:
-assess patient’s understanding of their illness and determine if they need further education about their illness and refer to medical staff if
required.
•Assess patient’s understanding and attitude to current and previous medication therapy including:
-indication
-perceived effectiveness
-perceived problems attributed to medicines
-current monitoring
-reasons for changes to medicines.
•Assess patient’s ability to use medicines as prescribed, e.g. do they have swallowing difficulties?

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 Table 1.2 Detailed instructions for conducting a patient/carer medication history interview (contd)
•Assess whether there are factors preventing adherence, such as:
-insufficient knowledge of medicines
-confusion
-cost issues
-personal or cultural beliefs or attitudes
-physical limitations, e.g. poor vision, lack of strength or coordination.
•Assess patient’s adherence by asking questions such as: ‘People often have difficulty taking their medicines for one reason or another.
Have you had any difficulty taking your medicines?’ ‘About how often would you say you miss taking your medicines?’
•Use a non-judgmental, empathetic approach and open-ended questions.
•Where possible, supplement self-reported adherence with objective measures, e.g. dispensing records.
•Inform medical staff if significant areas of poor adherence are identified.
•Identify strategies to address poor adherence.
•Assess how medicines were managed before presentation:
-determine level of supervision/assistance needed for safe medicine administration at home, e.g. Was another person responsible for
obtaining and/or assisting with medicine administration? Was an adherence aid being used? If so, who packed it?
•Assess patient’s ability with respect to literacy, visual impairment, physical dexterity, cognition/memory and other disabilities.
•Assess need for additional adherence aids, e.g. large print, written information provided in a language other than English.

Obtain Patient’s Consent Details of the medication history may be entered on the
Where appropriate, obtain the patient’s consent before National Inpatient Medication Chart (NIMC).17 However,
requesting patient-specific information from other health the NIMC may be moved from the bedside when a new
professionals. Also: chart is commenced and there is insufficient space to
• explain the need to contact other health professionals record all the details required for a comprehensive history.
• request permission to obtain patient-specific A comprehensive medication history can be documented
information from other health professionals in a MMP, in paper or electronic format according to local
• obtain the patient’s consent before discussing policy. If the review is done in outpatients or a clinic then
medication details with their carer or the person the MMP or local equivalent rather than the NIMC should
managing their medicines. be used. The medication history must then form part of the
patient’s permanent health record.
Summarise Interview
Allow the patient/carer to ask questions about their Planned Admissions
medicines during and at the conclusion of the interview. Ideally, all preadmission clinics will have a pharmacist
At the conclusion of the interview: present and all patients admitted for elective admissions
• advise the patient/carer when a pharmacist will next will have their medication history taken and documented
visit and what to do if they have further questions by a pharmacist.
• summarise the important information and describe Patient-completed questionnaires used for
the expected plan for their medication management, preadmission assessment are often inaccurate.18 Encourage
e.g. medicines-related issues that need to be resolved, patients/carers to bring to the preadmission clinic:
different brands of medicine used. • all their medicines (prescription, non-prescription,
herbal and dietary supplements)
Document Medication History • medicines lists and repeat prescriptions
The information obtained in patient interviews should • any other information that could help accurately
be accurately documented and readily available to other record what they have been taking, e.g. ADR card.
healthcare providers involved in the care of the patient. Advise patient/carer on:
See Table 1.3 • continuing current medicines regimen until their
admission
Table 1.3 Documenting medication reconciliation • medicines that must be withheld and for how long
A medication history should include:1 before the admission
•patient details
• medicines that are contraindicated or may interact
•date with their planned treatment
•name, designation and contact details of person documenting • pre-medications required before admission.
the medication history Pharmacists should clearly document the plan for
•information sources ceasing medicines before procedures and the plan for
•list of medicines (prescription, non-prescription, CAMs, restarting them after the procedure.
recreational, recently ceased, taken intermittently). For each
On admission:
medicine include: generic and brand name, strength, dose form,
dose, route, administration schedule, duration of therapy/when • check if there have been changes to their medicines
medicine started, perceived indication (according to the patient) since the preadmission clinic appointment
•adverse drug reactions and allergies. • document and flag medicines-related problems to be
addressed before discharge, e.g. adherence.1
Information may be gathered over several interviews As not all elective admissions have preadmission
as the patient/carer recall their medicines. It is important processes, e.g. medical admissions, complete and
that the medication history documentation is easy to access document the medication history within 24 hours of
and update when new information becomes available. presentation or admission, or at least before the end of the
Address issues identified when taking the medication next working day after admission.
history as soon as possible.1

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Confirm Accuracy of the Medication History Table 1.4 Minimum requirements for medication
Determine if the medication history obtained from the reconciliation recording form
patient/carer requires confirmation with alternative Sources of information and contact details (where applicable):15
sources. Confirmation from a further source is required if: •carers/family
• the patient is not responsible for administration of •nursing home
their own medicines •community pharmacist
• a reliable medication history cannot be obtained from •GP
the patient/carer •community nurse
•patient’s own medicines
• elements of the medication history are unknown
•previous hospital records
• the medication history is complex •medication list.
• the medication history includes high-risk medicines.
General information:
Review the documented medication history and update
if new information becomes available during the episode •who manages the patient’s medicines
•location of the patient’s own medicines
of care. Appropriate sources to confirm accuracy of the
•immunisation status
medication history include: •contact information for GP, community pharmacist and
• patient’s relative/carer responsible for supervising residential aged care facility (if applicable).
medicine administration
Documented evidence:
• dispensing history from previous hospital admissions
and/or community pharmacies •indicate that each medicine in the patient’s medication history
has been reconciled on admission and discharge
• administration records from residential care or other •indicate variances in medication orders
health service organisations •explain action taken to reconcile discrepancies in medication
• other health professionals, e.g. GP, community nurse orders.
• patient’s electronic health record Other useful details:15,17
• patient’s medicines or medicines list
•prescriber’s plan for continuing/discontinuing medication for this
• patient’s prescriptions (community pharmacy,
episode of care
discharge/outpatient). •medicines that the patient has existing supplies of
If unable to confirm what medicines the patient was •medicines to supply on discharge
taking before presentation or admission, then document •administration and/or adherence aids used prior to presentation
that the medication history details obtained have not been •relevant information from adherence assessment
confirmed. •consent given by patient to contact other health professionals
•relevant information regarding patient understanding of their
medicines
Reconcile History with Prescribed Medicines •presenting complaint
Medication reconciliation should: •past medical history
• occur each time a patient is transferred from one episode •admission weight and height
of care to another and when new medication orders are •relevant biochemical data
written. Transfer may be within the organisation, on •risk assessment: level of independence and patient assessment
discharge or between providers of care •home visit or HMR referral recommended
•follow-up medical review via ambulatory or outreach clinic
• include review of the previous medication orders recommended
alongside new orders and the care plan •discharge tasks documented and signed for including: medication
• include review and resolution of discrepancies as they counselling, CMI provided, discharge medication record provided,
arise as well as available information to determine if discharge medication supplied, administration aid supplied,
discrepancies are intentional or non-intentional community liaison pharmacist referral, discharge summary
• include communication with the prescriber to resolve provided and where it has been sent.
medicines-related problems.
process.2 Minimum requirements for documenting
On Admission or Presentation medication reconciliation on a purpose-designed form are
Compare the best possible medication history with the listed in Table 1.4.
current medication orders in the context of the admission Wherever medication reconciliation is performed,
plan and the MMP and identify any discrepancies. Ensure the MMP or equivalent should be filed in the patient’s
that the patient has not been prescribed a medicine to which permanent health record for future access.
they have experienced an ADR/allergy. Medicine-related
problems with the patient’s current medicines regimen may During Inpatient Stay
be identified at this stage, see Chapter 2: Assessment of Check that the best possible medication history and current
current medication management and Chapter 3: Clinical medicines are accurately transcribed for every transition
review, therapeutic drug monitoring and ADR management. the patient makes from one episode of care to another or
All medication reconciliation information should be when a new medication chart is written.
documented in the patient’s MMP as part of their active
health record so that it is available to all healthcare On Discharge/Transfer
providers involved in the patient’s care. See Chapter 13: Check that the discharge/transfer medication orders match
Documenting clinical activities. current medication orders, the medicines supplied at
The MMP should remain with the patient’s active discharge and the discharge plan. Check that there is a plan
medication chart for the duration of the admission. It is then for recommencing medications withheld on admission
filed in the health record along with the medication chart and any changes noted.
on discharge. If the MMP is documented electronically The medication history should be listed in the
it should be readily available in the patient’s health discharge summary including the reasons for any changes
record. Information technology can facilitate medication between admission and discharge. Ensure that the details
reconciliation if it is devised to support a well-designed are included in the patient’s electronic health record.

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 Reconcile the patient’s own medicines with discharge/ 12. Taylor SE, Thompson B, Garrett K, et al. Comprehensive evaluation of the
transfer medication orders and discuss changes to role of a clinical pharmacist in the emergency department. Quality Improvement
Funding Final Report. Melbourne: Department of Human Services; 2003.
medicines during the episode of care and expected 13. Dooley MJ, Van de Vreede M, Tan E. Patient-completed medication
changes for discharge/transfer. Discuss with the patient histories versus those obtained by a pharmacist in a pre-admission clinic. J
what medicines will be required on discharge to ensure Pharm Pract Res 2008; 38: 216-18.
14. Society of Hospital Pharmacists of Australia. Committee of Specialty
continued supply. Obtain permission from the patient to Practice in Emergency Medicine. SHPA standards of practice in emergency
supply required medicines and remove ceased medicines medicine pharmacy practice. J Pharm Pract Res 2006; 36: 139-42.
for destruction. See Chapter 6: Facilitating continuity 15. Australian Commission on Safety and Quality in Health Care. National
medication management plan. Sydney: The Commission.
of medication management on transition between care 16. AIDET: acknowledge, introduce, duration, explanation and thank you. Gulf
settings. Breeze: Struder Group. Available from <www.studergroup.com/aidet>.
17. Australian Commission of Safety and Quality in Health Care. National
inpatient medication chart. Sydney: The Commission; 2009.
Supply Verified Information for Ongoing Care
18. Blennerhassett J, Graudins L. Medication safety and patient participation:
Ensure that verified information about the patient’s pharmacist, emergency department and beyond [letter]. J Pharm Pract Res
medicines is received by all involved in the patient’s care 2005; 35: 244.
(including the patient) on discharge. Ensure information 19. Society of Hospital Pharmacists of Australia. Clinical competency
assessment tool (shpaclinCAT version 2). In: SHPA standards of practice for
is included in the patient’s electronic health record. clinical pharmacy services. J Pharm Pract Res 2013; 43 (suppl): S50-S67.
Obtain patient consent before sharing any information 20. Australian Pharmacy Profession Consultative Forum. National competency
with other healthcare providers in line with privacy and standards framework for pharmacists in Australia. Deakin: Pharmaceutical
Society of Australia; 2010.
confidentiality legislation. 21. Australian Commission on Safety and Quality in Health Care. National
If the patient is being transferred to another episode safety and quality health service standards. Sydney: The Commission; 2011.
of care, supply comprehensive information to the
health professionals responsible for continuing the
patient’s medication management. Also provide relevant Table 1.5 Competencies and accreditation frameworks
information to the patient in accordance with their Relevant national competencies and accreditation
MMP. See Chapter 5: Providing medicines information standards and shpaclinCAT competencies
and Chapter 6: Facilitating continuity of medication shpaclinCAT19
management on transition between care settings.
Competency unit 1.1 Medication history
Provide the following verified information:
• any medicines issued at discharge/transfer and the 1.1.1 Relevant patient background
1.1.2 Introduction to consultation
source for further supply
1.1.3 Questioning technique
• discharge or transfer medicines list (complete and 1.1.4 Patient consent
accurate list of all current medicines) 1.1.5 Allergy and adverse drug reaction review
• explanation of the changes to therapy during the 1.1.6 Accurate medication details
episode of care. 1.1.7 Patient’s understanding of illness
The method of information delivery should be timely 1.1.8 Patient’s experience of medicines use
and mutually agreed among healthcare providers. If 1.1.9 Documentation of medication history
1.1.10 Confirmation of medication history
required create a current list of medicines. 1.1.11 Adherence assessment
Encourage patients/carers to have a current list of
Competency unit 1.2 Assessment of current medication
medicines and to bring the list with them to each health
management and clinical review
service organisation or health professional that they
attend.17 1.2.1 Medication reconciliation
Table 1.5 lists the competencies and accreditation Competency unit 1.3 Identification, prioritisation and
frameworks that are relevant to this chapter. resolution of medicines-related problems
1.3.2 Identification of medicines-related problems
References
1.3.3 Prioritisation of medicines-related problems
1. Australian Pharmaceutical Advisory Council. Guiding principles to achieve
continuity in medication management. Canberra: The Council; 2005. 1.3.4 Resolution of medicines-related problems
2. Poon EG. Medication reconciliation: whose job is it? Rockville: Agency for 1.3.5 Documentation of medicines-related problems
Healthcare Research and Quality. Morbidity and mortality rounds on the web; Competency unit 1.5 Discharge/transfer facilitation
2007. Available from <webmm.ahrq.gov/case.aspx?caseID=158>.
3. How-to guide: prevent adverse drug events (medication reconciliation). 1.5.1 Reconciliation of medicines on transition between care
Cambridge: Institute for Healthcare Improvement; 2011. Available from settings
<www.ihi.org>.
4. Institute for Safe Medication Practices. Medication safety self assessment for Competency unit 2.1 Problem solving
Australian hospitals. Sydney: Clinical Excellence Commission; 2007. 2.1.2 Access information
5. Institute for Safe Medication Practices. Building a case for medication
2.1.3 Abstract information
reconciliation. ISMP Med Saf Alert 2005; 21 April.
6. Department of Human Services Victoria. Safer systems—saving lives.
2.1.4 Evaluation and application of information
Preventing adverse drug events. Melbourne: The Department; 2005. Competency unit 2.4 Communication
7. Carter MK, Allin DM, Scott LA, Grauer D. Pharmacist-acquired medication
histories in a university hospital emergency department. Am J Health Syst 2.4.1 Patient and carer
Pharm 2006; 63: 2500-3. 2.4.2 Pharmacy staff
8. Reeder TA, Mutnick A. Pharmacist-versus physician-obtained medication 2.4.3 Prescribing staff
histories. Am J Health Syst Pharm 1008; 65: 857-60. 2.4.4 Nursing staff
9. Tan VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. 2.4.5 Other health professionals
Frequency, type and clinical importance of medication history errors at
admission to hospital: a systematic review. CMAJ 2005; 173: 510-15. Competency unit 2.5 Personal effectiveness
10. De Winter S, Spreit I, Indevuyst C, Vanbrabant P, Desruelles D, Sabbe M,
et al. Pharmacist-versus physician acquired medication history: a prospective
2.5.1 Prioritisation
study at the emergency department. Qual Saf Health Care 2010; 19: 371-5. 2.5.3 Efficiency
11. Stowasser DA, Collins DM, Stowasser M. A randomised controlled trial 2.5.4 Logic
of medication liaison services-patient outcomes. J Pharm Pract Res 2002; 32: 2.5.5 Assertiveness
133-40. 2.5.6 Negotiation
2.5.7 Confidence

Journal of Pharmacy Practice and Research Volume 43, No. 2 (suppl), 2013. S11
 Competency unit 2.6 Team work
2.6.2 Interdisciplinary team
Competency unit 2.7 Professional qualities
2.7.2 Confidentiality
2.7.4 Responsibility for patient care
National competency standards framework for
pharmacists20
Standard 1.1 Practise legally
3 Respect and protect the consumer’s right to privacy and
confidentiality
4 Support and assist consumer consent
Standard 2.1 Communicate effectively
1 Adopt sound principles for communication
2 Adapt communication for cultural and linguistic diversity
3 Manage the communication process
4 Apply communication skills in negotiation
Standard 2.2 Work to resolve problems
1 Analyse the problem/potential problem
2 Act to resolve the problem/potential problem
Standard 4.2 Consider the appropriateness of prescribed
medicines
1 Gather relevant information
Standard 6.1 Assess primary health care needs
1 Elicit relevant clinical information
Standard 7.1 Contribute to therapeutic decision-making
1 Obtain accurate medication history
National safety and quality health service standards21
Standard 4 Medication safety: documentation of patient
information
4.6 Accurate medication history
4.7 Documentation of adverse drug reactions
4.8 Review and reconciliation on admission and transfer
Standard 4 Medication safety: continuity of medication
management
4.12 Current comprehensive list of medicines and the reason for
change
Standard 4 Medication safety: communicating with patients and
carers
4.15 Current medicines information

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