Safe Prescribing Practices for Unseen Patients

Introduction to Medication Reconciliation

The British Journal of Pharmacology recommends that prescribers should not take over prescriptions for a patient without first conducting a thorough medication reconciliation and reviewing their complete medical history, as this creates substantial risk for medication errors that can lead to patient harm 1, 2
67% of medication histories contain at least one prescription error, with 22% having potential to cause significant patient harm 1

The British Journal of Pharmacology suggests that complete medication history, including all prescription medications, over-the-counter drugs, herbal remedies, and alternative treatments, should be obtained and reviewed before assuming prescribing responsibility 1, 2, 3
Drug allergies and previous intolerances should be documented with specific details, including dose, reaction type, temporal relationship, and susceptibility factors 1, 2
Current medical diagnoses and active problems should be reviewed to understand the indication for each medication 3
Recent laboratory investigations relevant to medication monitoring should be obtained 1
Previous prescriber's treatment rationale and any documented medication adjustments should be reviewed 4

The American Journal of Kidney Diseases outlines that after obtaining the medication list, the prescriber should present the list to themselves for review and resolution of any medication discrepancies 5, 6, 7
The reconciliation should be documented in the medical record with date and prescriber's name 5, 6, 7
A plan of action should be created for any unresolved discrepancies 5, 6
The updated medication list should be shared with the patient and permission obtained to communicate with other healthcare providers 5, 6, 7

The British Journal of Pharmacology highlights that anticoagulants, especially warfarin, require extra scrutiny due to increased error rates 1, 2
Insulin and other antidiabetic agents, diuretics, amiodarone and other antiarrhythmics, and central nervous system depressants also require careful review 1, 2, 6
Antihypertensives should be carefully monitored due to potential interactions and side effects 6

The British Journal of Pharmacology states that adequate medical records should be available for review before taking over prescriptions 1
If the patient cannot provide a reliable medication history and no collateral sources exist, it may be necessary to refuse taking over prescriptions 1
High-risk medications prescribed without recent monitoring data may also be a reason to refuse taking over prescriptions 1, 6

The British Journal of Pharmacology suggests requesting pharmacist involvement to obtain better medication histories and reduce medication error rates 1, 2
Scheduling an initial visit for medication review before assuming prescribing responsibility may also be necessary 5
Obtaining records from the previous prescriber before the patient runs out of medication can help ensure continuity of care 5, 4

The British Journal of Pharmacology notes that older adults are more susceptible to medication errors and adverse effects 1, 8
Patients in nursing homes, receiving home care, or in surgical/ICU settings face higher error risks 1
Multiple prescribers increase the risk of duplications and interactions, requiring extra caution 1

The European Society of Cardiology recommends matching each of the patient's conditions with their medications to identify potentially inappropriate medications, and using validated tools such as Beers criteria, STOPP/START criteria, or Medication Appropriateness Index for older adults 9, 10
Approximately 30-75% of older adults do not take medications as prescribed, and 33-69% of drug-related hospital admissions are attributable to non-adherence, highlighting the need for comprehensive medication reconciliation 9
The American Geriatrics Society suggests that 44% of patients at hospital discharge receive at least one potentially inappropriate medication, emphasizing the importance of careful medication review 10

The European Heart Journal recommends providing clear written and verbal instructions for each medication with specific indication, and educating the patient about potential adverse effects 10
Patients with polypharmacy are at increased risk of medication errors and adverse effects, with 67% of medication histories containing at least one error, and 22% having potential for significant harm 9