All patients admitted to hospital for inpatient care must have a review of their medication chart/s (WA HMC, WA Anticoagulant Chart, Insulin Chart etc.) completed by a clinical pharmacist by ENCD. If unable to undertake daily review, risk assessments must be conducted to determine the frequency of ongoing chart review, based on the acuity or clinical risk of patients. The tasks associated with chart review undertaken by a clinical pharmacist should include, but are not limited to: • identifying, clarifying, monitoring and assessing medications prescribed for potential adverse drug reactions and/or drug interactions • ensuring that the prescription meets legal requirements • identifying changes in dose, frequency, formulation and route of administration to regular medications • providing clarification of: Antibacterials • Aminoglycosides (amikacin, gentamicin and tobramycin) • Glycopeptides (teicoplanin and vancomycin) Anticoagulants • Unfractionated heparin • Warfarin • Rivaroxaban • Dabigatran • Apixaban Antiepileptics • Phenytoin • Sodium valproate • Carbamazepine Bronchodilators • Theophylline Psychotropics • Lithium • Clozapine 16 o medication names from trade names to generic Therapeutic Goods Administration (TGA) approved medication names where applicable (exceptions may include insulin, asthma/COPD inhalers) o doses for all medications, particularly for all paediatric patients and inpatients with compromised renal or liver function, o dosing times with respect to meal times or other ward/team regimes o medication orders to ensure no error-prone abbreviations are used o form of medication required by the patient and how it is to be administered. • providing reconstitution directions and administration guidelines (or where to find them) • monitoring the patient's response to the medication(s) (such as therapeutic drug monitoring and, biochemistry parameters) • identifying new medications and providing or arranging for education, if required • documenting the review in the appropriate signoff box on the medication chart.

Number of patients that have been reviewed by a clinical pharmacist within one day of admission

Number of patients in sample

Over the 6 month collection period a total of 5-10 patients per ward at the hospital should be audited to ensure that data is collected from each clinical area. An audit tool has been developed by the WA Medication Safety Network to facilitate documentation - Medication Reconciliation Audit Tool. Selection of a random sample of current inpatients is recommended. Sample size will depend on available resources and facility size, but the following recommendations are based on the number of beds included in the program: 150 or more: 20% of patients 30 – 149: 30 patients Less than 30: Actual number of beds

Medication Review Reporting Form to the Department of Health. Not publicly reported based on available evidence

www.health.wa.gov.au/Articles/J_M/Medication-reconciliation www.health.wa.gov.au/~/media/Files/Corporate/general-documents/safety/PDF/1015-Med-Rec-Audit-Tool-Guidelines.pdf