Post operative medications review

Careful consideration is needed to ensure that medication is optimal in the peri-operative period. This may include starting new medicines or more commonly planning when and how patients will take their own medication.

During the review of a patient’s medication, the below should be considered (please note that local guidelines should always be followed regarding changes to specific medications mentioned).

• What are the patient’s normal medications?
• What should be stopped and when should it be restarted?
• What should continue?
• Can anything be optimised?
• Is any anti-coagulation bridging therapy required?
• What should be started?
• Are there any additional specialist medications required?
• Are there any specialist bloods that need to be taken?
• Consideration of fluids and electrolyte replacements within the review
• Analgesia

What we’ve learnt

Our experience has been that sometimes it is the most basic things that can make a difference when it comes ensure patients receive optimal medicine management in the perioperative period. This includes:

• Good communications between the medical, surgical and ward teams are required with clear written instructions.
• Checking whether medications have been omitted and why (not just that they are prescribed or not).
• Ensuring antibiotics are reviewed and stopped appropriately.
• If a drug is not tolerated that an alternative is considered.
• Ensuring appropriate bloods are sent for required levels.
• If a patient is nil by mouth or has an NG in-situ can they still safely receive oral medication or is there an alternative route that can be used.
• Providing good junior doctor and nurse education and guidelines to follow.
• Make sure that patients are only discharged on required medications and appropriate referrals to specialist teams are made if there are changes.
• Medication which has been stopped should be clearly communicated to the patients GP.