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Medication Reconciliation
Kelly Cunningham* and Jill D. Goldenberg*
†
Key Pearls
• Medication reconciliation is the process of compiling an accurate
list of all medications a patient is taking at the time of admission;
comparing that list to all hospital admission, transfer and discharge
orders; resolving any discrepancies; and communicating the updated
list to the patient and follow-up provider at the time of hospital
discharge.
• Regulatory organizations, including the Joint Commission in the US,
recognize medication reconciliation as a key strategy to decrease
medication errors during transitions of care.
• One effective model of medication reconciliation utilizes pharmacists
to take medication histories, partner with physicians to clarify discrepancies, and communicate medication changes to patients and outpatient providers at hospital discharge.
• Recommended practices include adopting a standardized reconciliation tool; clearly defining responsibility and accountability for each
step of the process; specifying a time frame for completion of admission medication reconciliation; making the pre-admission medication
list easily accessible in the chart; targeting high risk patients for more
intensive interventions and empowering patients to actively maintain
a medication list.
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*Mount Sinai School of Medicine, New York, NY, USA.
• Hospitalists can contribute to medication reconciliation efforts by
serving as physician champions; modeling effective teamwork; helping integrate processes into provider workflow; leveraging information technology; and measuring the impact on clinically relevant
outcomes.
Background
Medication errors are common and often preventable causes of patient
harm. Patients are most vulnerable to medication errors during transitions
of care, such as hospital admission, transfers of service, location or level
of care during hospitalization, and at hospital discharge.
1
Studies have
shown that up to 67% of admitted patients have at least one discrepancy
between the prescription medication list obtained by the admitting
provider and the patient’s actual pre-admission medication regimen.
2
Furthermore, in up to 59% of cases, discrepancies occurring at the time of
admission have the potential to cause harm, particularly if the errors persist beyond discharge.
3
Discharge medication reconciliation errors are
also prevalent, with as many as 70% of patients having an unintentional
medication discrepancy at discharge, and nearly one-third of those discrepancies having the potential to cause harm.
4
The implications of these
errors are significant, resulting in post-discharge adverse drug events that
may lead to emergency room visits, hospital readmissions, and utilization
of other healthcare resources.
5,6
Medication reconciliation is a strategy to reduce the risk of potential
adverse drug events among patients transitioning across different care settings. Medication reconciliation is defined as the process by which a
patient’s medication list is obtained, compared, and clarified across different sites of care.
1
Specific steps in the process are detailed in Fig.1. The
process typically includes the following:
• Developing a list of medications that the patient is currently taking
• Generating a list of medications to be ordered
• Comparing these two lists
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K. Cunningham and J. Goldenberg
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Medication Reconciliation
p
Fig. 1. Steps of medication reconciliation.
• Resolving any discrepancies
• Communicating the new, reconciled list to the patient, appropriate
caregivers, and receiving provider
Evidence has supported the concept of medication reconciliation. In a study
of a pharmacist-based medication reconciliation program involving hospital
admission and discharge, Vira and colleagues found that 18% of patients had
at least one clinically important medication error, none of which had been
detected by usual clinical practice before medication reconciliation was conducted.
7
Other groups have demonstrated significant decreases in medication
errors by implementing comprehensive, multidisciplinary medication reconciliation programs.
1,8
Though these findings are encouraging, most published
studies have been limited by small sample sizes, single study sites, lack of
randomization, and a paucity of clinically relevant outcomes.
Recognizing that minimizing medication errors is a fundamental part
of patient safety, several organizations have emphasized medication reconciliation as a priority. The Institute for Healthcare Improvement highlighted medication reconciliation as a key intervention for its 100,000 and
5 Million Lives Campaigns.
9,10
In 2005, the Joint Commission added medication reconciliation to its list of National Patient Safety Goals (NPSG),
setting the expectation that hospitals “accurately and completely reconcile
medications across the continuum of care”.
11
This NPSG requires healthcare organizations to develop and implement a process for obtaining and
documenting the full list of medications a patient is taking at the time of
admission, comparing that list to medications ordered for the patient while
under the care of the hospital, and communicating the complete list to the
next provider of care. In addition, a standard was added for institutions to
provide the reconciled list of medications to the patient and/or family at
the time the patient leaves the organization’s care.
12
Barriers
The process of medication reconciliation is complex and, as a result, can
be challenging for organizations to put into practice. Numerous barriers to
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K. Cunningham and J. Goldenberg
implementation have been identified, comprising patient, provider and
system factors. For instance, admission history taking can be compromised by the providers’ lack of time and knowledge required to perform
an accurate medication history; unclear expectations of who is responsible for taking the history; patients’ lack of knowledge of their medications; and multiple, often conflicting, sources of medication information.
In addition, many medication reconciliation programs lack the integration
of history taking and medication ordering or fail to incorporate these
processes into providers’ workflow. Pervasive issues such as increasing
numbers of handoffs, low health literacy, and limited resources for
staffing and information technology further complicate the effective
implementation of medication reconciliation practices.
Successful Strategies
Institutions have taken varied approaches to operationalizing medication
reconciliation. Successful programs have engaged different types of
healthcare providers and have built processes around both paper-based and
electronic interventions, depending on available resources. One effective
strategy is to leverage the skills of pharmacists. A randomized controlled
trial conducted by Schnipper and colleagues evaluated an intervention
using pharmacists to compare discharge medications to pre-admission
medications, reconcile discrepancies with the assistance of the physician,
and perform discharge medication counseling. The authors found a significant decrease in the occurrence of preventable adverse drug events and
preventable medication-related emergency room visits and hospital readmissions 30 days post-discharge as compared with usual care.
14
Programs can also take advantage of health information technology to
help automate processes and streamline workflow. In one study, the use of
a computerized medication reconciliation tool that facilitated the creation
of a pre-admission medication list and the reconciliation of admission and
discharge medication regimens significantly decreased the number of
potential adverse drug events as compared with usual care, when used in
the setting of redesigned provider roles and workflows.
15
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Medication Reconciliation
Successful programs share common features, such as having buy-in
of frontline staff, clearly defined roles and procedures, executive sponsorship, involvement of multidisciplinary teams, and mechanisms for assessing process and outcome measures. Based on the available evidence,
hospital medicine and patient safety organizations recommend specific
practices, including:
10,16
• Adopting a standardized tool for use in reconciling medications
• Ensuring that the pre-admission medication list is readily accessible
in the chart
• Specifying a time frame for completion of admission medication rec-
onciliation
• Identifying the highest risk patients (i.e. the elderly, low health liter-
acy, on many medications)
• Empowering each patient to maintain a medication list and/or per-
sonal health record
Remaining Challenges
Despite the progress that has been made in the arena of medication safety,
numerous challenges remain. Basic concepts such as standardized definitions of what constitutes a medication and designating responsibility and
accountability for completing each step in the process must be clarified.
The need for an accurate medication history remains paramount, as evidence suggests that most errors originate during the admission medication
history; therefore, resources must be invested in providing the knowledge,
time and information sources to aid providers in accurately completing
this critical initial step.
17
Furthermore, efficient and sustainable medication reconciliation processes will require better integration of different
stages to minimize duplication of work and transcription errors.
Institutions must take advantage of health information technology, where
available, to facilitate order entry, prescription writing and maintenance of
correct medication lists, to offer timely decision support, and to make
possible the sharing of information among different institutions. Lastly,
and perhaps most importantly, hospitals must focus on the process of
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medication reconciliation with the goal of patient safety rather than simply satisfying accreditation requirements.
Hospitalists have been instrumental in developing and implementing
medication reconciliation in their institutions and in conducting studies to
measure the impact of these processes. In their roles as clinicians,
researchers, administrators and patient safety leaders, hospitalists are well
positioned to address these challenges and further advance the field by
developing best practices and collaborating on multi-center studies with
relevant clinical outcomes.
References
1. Rozich JD, Resar RK. (2001) Medication safety: One organization’s
approach to the challenge. J Clin Outcomes Manage 8: 27–34.
2. Lau HS, Florax C, Porsius AJ, et al. (2000) The completeness
of medication histories in hospital medical records of patients admitted
to general internal medicine wards. Br J Clin Pharmacol 49: 597–603.
3. Gleason KM, Groszek JM, Sullivan C, et al. (2004) Reconciliation of
discrepancies in medication histories and admission orders of newly
hospitalized patients. Am J Health Syst Pharm 61: 1689–95.
4. Wong JD, Bajcar JM, Wong GG, et al. (2008) Medication reconcilia-
tion at hospital discharge: Evaluating discrepancies. Ann Pharmacother
42: 1373–9.
5. Johnson JA, Bootman JL. (1995) Drug-related morbidity and mortality:
A cost of illness model. Arch Intern Med 155: 1949–56.
6. Forster AJ, Murff HJ, Peterson JF, et al. (2005) Adverse drug events
occurring following hospital discharge. J Gen Intern Med 20: 317–23.
7. Vira T, Colquhoun M, Etchells E. (2006) Reconcilable differences:
Correcting medication errors at hospital admission and discharge.
Qual Saf Health Care 15: 122–6.
8. Murphy EM, Oxencis CJ, Kaluck JA, Meyer DA, Zimmerman JM.
(2009) Medication reconciliation at an academic medical center:
Implementation of a comprehensive program from admission to
discharge. Am J Health-Syst Pharm 66: 2126–31.
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9. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. (2006) The
100 000 Lives Campaign: Setting a goal and a deadline for improving
healthcare quality. JAMA 295: 324–7.
10. Institute for Healthcare Improvement. (2008) 5 Million Lives
Campaign. Getting started kit: Prevent adverse drug events (medication reconciliation) how-to guide. Cambridge, MA. Available at
www.ihi.org.
11. The Joint Commission. (2006) Using medication reconciliation to
prevent errors. Sentinel Event Alert. Available at: http://www.
jointcommission.org/SentinelEvents/SentinelEventAlert/sea_35.htm
Accessed May 20, 2010.
12. Joint Commission on Accreditation of Healthcare Organizations.
(2007) 2008 National Patient Safety Goals. Joint Commission
Perspectives 27: 10–22.
13. The Joint Commission. (2010) Medication reconciliation National
Patient Safety Goal to be reviewed, refined. Available at: http://www.
jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
nspg8_review.htmAccessed May 20, 2010.
14. Schnipper JL, Kirwin JL, Cotugno MC, et al. (2006) Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 166: 565–71.
15. Schnipper JL, Hamann C, Ndumele CD, et al. (2009) Effect of an
electronic medication reconciliation application and process redesign
on potential adverse drug events: A cluster-randomized trial. Arch
Intern Med 169: 771–80.
16. Greenwald JL, Halasyamani L, Greene J, et al. (2010) Making
inpatient medication reconciliation patient centered, clinically relevant
and implementable: A consensus statement on key principles and
necessary first steps. J Hosp Med 5: 477–85.
17. Pippins JR, Gandhi TK, Hamann C, et al. (2008) Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern
Med 23: 1414–22.
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K. Cunningham and J. Goldenberg
Transitions of Care: The Hospital
Discharge
Jill D. Goldenberg, Ramiro Jervis* and Kelly Cunningham
Key Pearls
• The transition from hospital to home is complex, error prone and can
result in post-discharge adverse events if poorly executed.
• The discharge process requires a team approach using the expertise of
physicians, nurses, pharmacists, and social workers.
• At discharge, special attention should be given to medication management, close follow-up post-discharge, and anticipatory guidance.
• Patients should receive clear verbal and written discharge instructions
tailored to their needs, literacy and native language.
• Communication with the receiving outpatient provider should occur
in the form of a verbal handoff and discharge summary or letter.
• Transitional care workers can facilitate the discharge process by
assisting with discharge medication management, scheduling of follow-up appointments, patient education, communication to the next
provider, follow-up phone calls and home visits.
Background
Adverse events have been linked to poor transitions and handoffs.
1
Moreover, these transitions have become increasingly common as patients
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Chapter
*Mount Sinai School of Medicine, New York, NY, USA.