Medicines reconciliation aims to ensure a patient's prescribed medications correspond to what they were taking before admission to minimize errors and harm. It involves collecting, checking, and communicating any discrepancies between current and past medications. Medicines Usage Reviews conducted by pharmacists allow patients to check their understanding of their conditions and medications. The pharmacist can identify issues like incorrect use, doses, or adverse effects that require follow up. MURs fall under level 1 reviews conducted with the patient and no medical records. Higher level reviews involve doctors, nurses, or pharmacists reviewing records with or without the patient.

1. Medicines Usage Reviews
TPP2 – Semester 2

2. Medicines Reconciliation
• The aim of medicines reconciliation in a hospital setting is to ensure that the prescribed medicines
correspond to those that the patient was taking before admission; it is more than just taking a drug
history, and requires consideration of the three C’s; checking, collecting and communicating.
• Medicines reconciliation seeks to minimise harm to the patient caused by medication errors,
prescribing errors and missed doses, whilst simultaneously reducing admissions and
readmissions that are caused by medication harm. It provides prescribers with a fuller information
timeline that helps improve patient safety.

3. The Three C’s
• Collecting a medication background, checking current medications against prescribed
medications/medicines bought in with the patient, and communicating any changes or
discrepancies is the basis of how medicines reconciliation can provide benefit to patients.
• Sources of drug history include; medicines the patient has bought in with them, prescriptions the
patient has on them, verbal communication with the patient, verbal communication with a patients’
relative that is present, information obtained through electronic databases and phone calls to GPs
or pharmacies.
• Checking medications is important in the detection of intended changes, and unintended changes.
Intended changes to medication will have been agreed with the prescriber, whereas unintended
changes can arise due to errors, omissions and additions.
• Communication is important, so that the patient is involved in their care and can make choices
where appropriate. Consent is also important in this regard. The clinician caring for the patient
should be free to discuss discrepancies, alter prescriptions if necessary and inform the patient
about changes. Changes should also be documented on the patient’s medical notes, the patient’s
drug chart and should be written in the hospital discharge summary.

4. MUR
• Medicines Usage Reviews (MURs) were introduced in 2005 as an advanced service for
community pharmacies. They focus on making sure patients understand how to use their
medications, when to use them and why they must use them.
• Pharmacists can decide which patients to offer MURs to, but at least half of the patients must fall
under National Patient Targets.
• National Patient Targets are groups of patients to which MURs should be offered, and include the
following groups; those on at-risk medications (i.e. anticoagulants, NSAIDs, antiplatelets and
diuretics); patients with a respiratory disease; patients who have recently been discharged from
hospital, having had a medication change during their stay; and patients with or who are at risk of
cardiovascular disease and regularly being prescribed at least four medicines.
• An MUR is different from Clinical Medication Reviews and Medication Reviews. The former is
consultation undertaken to assess patient’s illness and drug treatment (not conducted by non-
prescribing pharmacists). The latter is a review undertaken to optimise impact of therapy, reduce
harm caused by medications, and reduce wastage.
• MURs allow the patient to check their understanding of their own condition(s) and a professional
to check the effective use of medicines. The pharmacist is ideally placed to detect potential
formulation issues, and recommend changes to dose, strength or product. They are also well-
placed to identify adverse effects that may require reporting.

5. Levels of Review
• MURs are level 1 reviews, that are conducted by pharmacists in the presence of the patient, with
no access to patient notes.
• Medication reviews are level 2 services that are conducted by doctors, specialist nurses, CCG
pharmacists and NMPs in the absence of the patient, with access to full patient records.
• Clinical medication reviews are the level 3 reviews, the highest category. They are conducted by
doctors, CCG pharmacists, specialist nurses and NMPs in the presence of the patient, with full
access to the patient’s medication history and notes.
• Medicines optimisation focuses on a patient-centered approach to care in which the patients’
experience, evidence-based medicine, safe use of medicines and optimal therapy are all
considered, so that patient outcomes can be improved.

6. Conducting an MUR
• When conducting an MUR, the pharmacist should be able to communicate effectively, which
involves adequate eye-contact, reading of non-verbal cues, removing distractions and holding the
conversation in a private area, such as a consultation room.
• The MUR should begin with an introduction, perhaps by asking a few general questions like how
their day is going, what they are up to recently etc. Then the main body of the MUR should consist
of at first open-ended, then closed questions to identify issues, prioritise them and develop action
plans based on who should be following up what issues.
• Leading questions should be avoided to allow the patient to be truthful and sure in their responses
to your questions. Words such as “how” and “what” are better and less accusatory than “why”.
• Some areas may be sensitive to certain patients, such as age and nature of some adverse effects.
Leaving these sorts of questions until later can be better, as the patient is more relaxed in the
conversation and willing to divulge information.

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