Percentage of patients whose current medicines are documented and reconciled at admission

Number of patients whose current medicines are documented and reconciled at admission. The steps involved are 1. obtain a best possible medication history, 2. confirm the accuracy of the history, 3. reconcile the history with prescribed medicines, 4. supply accurate medicines information. The process and documentation for these steps should be determined by each institution with clear designation of roles and responsibilities and standard documentation of processes irrespective of professional discipline. Current medicines refers to all medicines taken prior to admission including complementary medicines and non-prescribed treatments. Documented means the steps that have been undertaken are explicitly documented in the medical record. Documentation may include use of the dedicated area on the NIMC or other purpose-designed form or medicines management plan, which ultimately forms part of the medical record. If used they should be dated and signed. At admission means this documentation is completed by the end of the next calendar day after admission. Reconciliation performed at a preadmission clinic is acceptable.

Number of patient records in sample

Patients admitted to hospital for less than 24 hours, trauma patients and patients admitted direct to ICU

Discharge documentation, medication charts, medication management or reconciliation forms and medical records

Recommended for local quality improvement processes. Not regularly reported at national level.

Australian Commission on Safety and Quality in Health Care and NSW Therapeutic Advisory Group Inc. (2014), National Quality Use of Medicines Indicators for Australian Hospitals. ACSQHC, Sydney www.safetyandquality.gov.au/sites/default/files/migrated/SAQ127NationalQUMIndicatorsV14-FINAL-D14-39602.pdf page 56