What is Medication Reconciliation?

• Explain the concept of medication reconciliation
• Describe the goal of medication reconciliation

Introduction to Medication Reconciliation Video

This brief introductory video (4:35 minutes) was created by ISMP Canada for Safer Healthcare Now! (SHN!). SHN! is a national campaign aimed at improving the safety of patient care through learning, sharing and implementing interventions such as medication reconciliation that are known to reduce avoidable adverse events.

Medication Reconciliation is a formal process in which healthcare providers partner with patients and their families to ensure accurate and complete medication information transfer at interfaces of care. This includes admission and discharge from a hospital or changes in care setting, service, or level of care.

From: Wong, Jacqueline D. Bajcar, Jana M. Wong, Gary G. Alibhai, Shabbir M H. Huh, Jin-Hyeun. Cesta, Annemarie. Pond, Gregory R. Fernandes, Olavo A. Medication reconciliation at hospital discharge: Evaluating discrepancies. Annals of Pharmacotherapy. 42(10):1373-9, 2008 Oct.

The Medication Reconciliation Process

The process of medication reconciliation involves the following key components:

1. Obtaining the most complete and accurate list possible of the patient’s current regularly taken medications, known as the Best Possible Medication History (BPMH).
2. Using the BPMH when writing admission, transfer and discharge medication orders.
3. Comparing the BPMH with the admission, transfer or discharge medication orders, identifying and bringing any discrepancies to the attention of the team and, if appropriate, making changes to the orders and documenting all changes.

Goal of Medication Reconciliation

The ultimate goal of medication reconciliation is to prevent adverse drug events (ADEs) at all interfaces of care (admission, transfer and discharge), for all patients. The aim is to eliminate undocumented intentional discrepancies and unintentional discrepancies by reconciling all medications, at all interfaces of care.

An undocumented intentional discrepancy occurs when the prescriber (usually the physician) intentionally adds, changes or discontinues a medication the patient was taking prior to admission but this is not clearly documented in the patient’s medical record.

An unintentional discrepancy occurs when the prescriber (usually the physician) unintentionally changes, adds or omits a medication the patient was taking prior to admission.

Preventing of Medication Errors

Types of medication errors that can be prevented by reconciling medications may include:

• failure to prescribe clinically important home medications while in hospital
• incorrect doses or dosage forms
• missed or duplicated doses resulting from inaccurate medication records
• failure to clearly specify which home medications should be resumed and/or discontinued at home after hospital discharge
• duplicate therapy at discharge (result of brand/generic name combinations or hospital formulary substitutions)

Examples of Medication Reconciliation

Example of an Undocumented Intentional Discrepancy

A patient receiving atenolol for hypertension was admitted for surgery. The admitting resident did not order atenolol on admission due to concerns about perioperative hypotension. The reason for not ordering atenolol was not documented in the medical record. The patient was discharged on the third postoperative day and was given a discharge prescription that did not include atenolol. The patient was unsure whether to resume treatment with atenolol at home and called her family doctor for advice. The family doctor called the patient’s surgeon to clarify the discrepancy. The surgeon did not know why the atenolol was stopped while in hospital and called the hospital pharmacy. The pharmacy did not have a record of the change so the pharmacist on the surgical unit tried to contact the admitting resident but the resident was no longer on the service.

Examples of an Unintentional Discrepancy

1. An elderly woman was admitted to a general medicine unit with a diagnosis of community-acquired pneumonia. Antibiotics and symptom management were ordered and started. Two days later the patient had a myocardial infarction and it was found that a beta-blocker (cardiac medication) had been unintentionally omitted on admission.
2. A patient was admitted for total knee replacement surgery. After four or five days the patient was not motivated and refused to get out of bed. The family mentioned to the nurse that the patient had been on an antidepressant medication prior to admission and it had not been ordered while in hospital. The medication was ordered. It took approximately one week for the medication to work again, resulting in a prolonged hospital stay.

Exercise

This excercise is also available as a PDF.

Think about the patient most recently admitted to your service and answer the following questions:

• Did the patient or family bring their medications to the hospital?
  • Were the medications properly labeled and stored in their original containers or a medication compliance aid (e.g., dosette)?
  
• Did the patient have a medication list?
  • Was the list from another healthcare provider or was it written by the patient?
• Did you have to contact the patient’s family doctor or pharmacist to clarify something about their medications?
  • What information did you need and were you able to get it?

Summary

Medication Reconciliation is a process designed to prevent medication errors at all interfaces of care (admission, transfer and discharge). It involves three steps:

1. Obtaining the most complete and accurate list possible of the patient’s regularly taken home medications.
2. Using the list when writing medication orders.
3. Comparing the list with the patient’s admission, transfer or discharge orders, identifying and bringing any discrepancies to the attention of the team and, if appropriate, making changes to the orders and documenting all changes.