Table 2.
Examples of non-reconciled inpatient episodes
| Patient demographic and diagnostic information: 60-year-old female presented with unstable angina on a background of ischaemic heart disease, dyslipidaemia, raised body mass index, asthma/chronic airways obstruction and hiatus hernia. | ||||
|---|---|---|---|---|
| Pre-admission medication list | Changes made | Final inpatient prescription and administration chart | Discharge prescription | Discharge summary |
| Elantan LA [Isosorbide mononitrate long acting (LA)] 25 od | Discontinued | \\ | Nil mentioned | Nil mentioned |
| Becotide 250 inh (Beclometasone inhaler) 2 puffs bd | 0 | Becotide 250 inh 2 puffs bd | Becotide 250 inh 2 puffs bd | Becotide 250 inh 2 puffs bd |
| Spiriva (Tiotropium) 18 mcg 1 puff od | 0 | Spiriva 18 mcg 1 puff od | Spiriva 18 mcg 1 puff od | Spiriva 18 mcg 1 puff od |
| Omeprazole 20 mg od | Increased to 40 mg od | Omeprazole 40 mg od | Omeprazole 40 mg od | Omeprazole 40 mg od |
| Atenolol 25 mg od | 0 | Atenolol 25 mg od | Atenolol 25 mg od | Atenolol 25 mg od |
| Detrusitol (Tolterodine) 1 mg bd | 0 | Detrusitol 1 mg bd | Detrusitol | Detrusitol 1 mg bd |
| Aspirin 75 mg od | 0 | Aspirin 75 mg od | Aspirin 75 mg od | Aspirin 75 mg od |
| Omacor (Omega III) 1 caps od | 0 | Omacor 1 caps od | Omacor 1 caps od | Omacor 1 caps od |
| Flurazepam 30 mg no | 0 | Flurazepam 30 mg no | Omitted | Omitted |
| Diazepam 5 mg tds | 0 | Diazepam 5 mg tds | Diazepam | Diazepam 5 mg bd |
| Pravastatin 20 mg no | 0 | Pravastatin 20 mg no | Pravastatin 20 mg no | Pravastatin 20 mg no |
| Potential for patient harm | Minor | |||
| Potential for unplanned re-admission within 3 months | Low | |||
| Patient demographic and diagnostic information: 75-year-old male presented with ischaemic heart disease on a background of atrial fibrillation, diabetes and congestive cardiac failure. | ||||
|---|---|---|---|---|
| Pre-admission medication list | Changes made | Final inpatient prescription and administration chart | Discharge prescription | Discharge summary |
| Clopidogrel 75 mg od | 0 | Clopidogrel 75 mg od | Clopidogrel 75 mg od | Clopidogrel 75 mg od |
| Protium (Pantoprazole) 40 mg od | 0 | Protium 40 mg od | Protium 40 mg od | Omitted |
| Atorvastatin 40 mg od | 0 | Atorvastatin 40 mg od | Atorvastatin 40 mg od | Atorvastatin 40 mg od |
| Amlodipine 10 mg od | 0 | Amlodipine 10 mg od | Amlodipine 10 mg od | Amlodipine 10 mg od |
| Aspirin 75 mg od | 0 | Aspirin 75 mg od | Aspirin 75 mg od | Aspirin 75 mg od |
| Bisoprolol 5 mg od | 0 | Bisoprolol 5 mg od | Bisoprolol 5 mg od | Bisoprolol 5 mg od |
| Warfarin | Held | ‘Hold’ | Nil mentioned | ‘Wa’ |
| Burinex (Bumetanide) 1 mg od | Changed to furosemide | Furosemide 40 mg od | Furosemide 40 mg od | Furosemide 40 mg od |
| Perindopril 4 mg od | 0 | Perindopril 4 mg od | Perindopril 4 mg od | Perindopril 4 mg od |
| Insulin Novorapid (Aspart) 18 units tds | 0 | Insulin Novorapid 18 units tds | Insulin Novorapid 18 units tds | Insulin Novorapid 18 units tds |
| Spironolactone 25 mg od | 0 | Spironolactone 25 mg od | Spironolactone 25 mg od | Spironolactone 25 mg od |
| + Iron 1 bd | Iron 1 bd | Iron 1 bd | Iron 1 bd | |
| Potential for patient harm | Moderate | |||
| Potential for unplanned re-admission within 3 months | Medium | |||
| Patient demographic and diagnostic information: 89-year-old female presented with malaena, diagnosed with gastric carcinoma and liver metastases on a background of aortic stenosis, mitral regurgitation, hypothyroidism and atrial fibrillation. | ||||
|---|---|---|---|---|
| Pre-admission medication list | Changes made | Final inpatient prescription and administration chart | Discharge prescription | Discharge summary |
| Pravastatin 40 mg od | 0 | Pravastatin 10 mg od | Pravastatin 10 mg od | Pravastatin 10 mg od |
| Warfarin | Discontinued by consultant geriatrician | \\ | \\ | Warfarin |
| Bisoprolol 2.5 mg od | Bisoprolol 2.5 mg od | Bisoprolol 2.5 mg od | Bisoprolol 2.5 mg od | |
| Eltroxin (Levothyroxine) 50 mcg od | Eltroxin 50 mcg od | Eltroxin 50 mcg od | Eltroxin 50 mcg od | |
| + Losec (Omeprazole) | Losec 40 mg od | Losec 40 mg od | Omitted | |
| ‘Consider bone protection on discharge’ | Nil | Nil | Nil mentioned | |
| + Digoxin | Digoxin 62.5 mcg od | Digoxin 125mcg od | Omitted | |
| Potential for patient harm | Severe | |||
| Potential for unplanned re-admission within 3 months | High | |||
This table presents verbatim the entries made in the patient's healthcare record. Details in italics represent information added by the authors for explanatory purpose. The bold font indicates where non-reconciliations were identified. Bd, twice daily; mcg, microgram; mg, milligram; nocte, at night; od, once daily; tds, three times daily.