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Describe the characteristics that medication reconciliation processes used in various health care settings should include


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The Role of Medication Reconciliation in

Ensuring Patient Safety

Release Date: 07/14/2011 Expiration Date: 07/14/2014


Kathryn L Haldiman MS, RN



Kathryn Haldiman has no actual or potential conflict of interest in relation to this program.



PharmCon Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Program No.: 0798-000-11-046-H05-P Credits: 1 contact hour, 0.1 CEU Nursing

Pharmaceutical Education Consultants, Inc. has been approved as a provider of continuing education for nurses by the Maryland Nurses Association which is accredited as an approver of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation.

Program No.: N-676



This accredited program is targeted nurses and pharmacists practicing in hospital and community pharmacies. Estimated time to complete this monograph and posttest is 60 minutes.


PharmCon, Inc does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced and objective. Occasionally, authors may express opinions that represent their own viewpoint. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions drawn by participants should be derived from objective analysis of scientific data presented from this monograph and other unrelated sources.

Program Overview:

To provide nurses and pharmacists with an understanding of the role of medication reconciliation and how it relates to improved patient safety strategies.


After completing this program, participants will be able to:

 Describe the characteristics that medication reconciliation processes used in various health care settings should include

 Describe methods of overcoming challenges related to medication reconciliation  Identify the role of the pharmacist in medication reconciliation (Pharmacist Only)


Haldiman – Medical Reconciliation in Patient Safety Page 1

The Role of Medication Reconciliation in Ensuring Patient Safety

The goal of this continuing education article is to describe the importance of medication reconciliation in ensuring patient safety for the intended audience of pharmacists. At the completion of this article, you will be able to:

1.) Describe characteristics that medication reconciliation processes used in various health care settings should include.

2.) Describe methods of overcoming challenges related to medication reconciliation. 3.) Identify the role of the pharmacist in medication reconciliation.

Medication Reconciliation: What it is and why it is important

Medication errors are preventable events that occur at any point during the medication-use process, including prescribing, transcribing, dispensing, administering, monitoring, or patient adherence to a medication. Adverse drug events (ADEs), which may or may not occur due to a medical error, include any injury that results from the use of a medication.[1] Numerous studies indicate that at least 25% of ADEs result from medication errors and, therefore, are


Medication errors and ADEs are common occurrences in the health care system, as well as the leading cause of injury and death related to medical errors in the United States. In a 2006 report, the Institute of Medicine estimated that the average hospitalized patient is subject to at least one medication error per day and 1.5 million preventable ADEs occur in various health care settings each year. [2] Approximately 7,000 deaths occur annually due to medication errors, [3] while 770,000 injuries and deaths each year are attributed to ADEs. [4] There is also a significant financial burden associated with medication errors and ADEs. Inpatient medication errors are estimated to cost approximately $16.4 billion annually [5] and outpatient medication errors may cost up to $4.2 billion each year. [6] Patients who experience an ADE have an increased average length of hospital stay by 8 to 12 days, resulting in higher hospital costs by $16,000 to $24,000, compared to those patients who do not have an ADE. [4]

Poor communication between health care providers and/or patients and caregivers during transitions of care has been attributed to cause 50% of medication errors and 20% of ADEs.[7] Care transition points are a time in a patient’s care that is particularly susceptible to potential medication errors, with inadvertent medication discrepancies occurring in nearly 33% patients at admission, 33% of patients at the time of transfer from one site of care to another within a


Haldiman – Medical Reconciliation in Patient Safety Page 2 hospital, and in 14% of patients at hospital discharge.[8] Medication reconciliation is a formal process that can reduce medication errors and ADEs by ensuring that health care providers and patients have a complete and accurate list of medications. Performing medication reconciliation correctly has been shown to decrease the rate of medication errors by 70% and reduce ADEs by 15%. [9]

Medication reconciliation is the process by which the most accurate patient medication list possible is obtained and compared to physician medication orders throughout the continuum of health care services.[10] The list must include the drug name, dosage, frequency, and route of administration for all prescription medications, over-the-counter medications, vaccinations, supplements, and vitamins. In a hospital setting, the patient medication list would be compared to admission, transfer, and discharge medication orders at each transition point, including changes in patient care settings, practitioners, teams, or services, or level of cares. The goal of medication reconciliation is to ensure that the patient is receiving and taking the correct

medications. Medication reconciliation includes the three steps of verification, clarification, and reconciliation. Verification involves the collection of an accurate medication history from the patient, family, or other health care professionals involved in the patient’s care. Clarification is ensuring that the medication name, dosage, route, and time of administration are accurate.

Finally, reconciliation includes the documentation of any changes made to the medication orders. [10]

Medication errors represent a frequent cause of sentinel events reported to the Joint Commission (TJC) through a voluntary sentinel event reporting program. [11] Because of the patient safety implications, since 2005, TJC has included medication reconciliation as a National Patient Safety Goal (NPSG) that applies to all care settings including hospitals, ambulatory care, behavioral health, home care, long-term care, and office-based surgery centers. Many health care organizations have struggled to develop and implement the processes necessary for medication reconciliation since its inclusion as a NPSG. Medication reconciliation as a NPSG was placed under review by the TJC in 2009 due to this widespread difficulty and health care organizations were not formally scored on this goal during surveys from 2009 to 2010. After revising the NPSG related to medication reconciliation, TJC will again formally score this goal effective July 2011. [12] TJC’s commitment to including medication reconciliation as a NPSG demonstrates


Haldiman – Medical Reconciliation in Patient Safety Page 3 the importance of the process in ensuring patient safety. Medication reconciliation is a safety goal that transcends the continuum of care and impacts all health care settings.

Methods of Ensuring Medication Reconciliation

Although the importance of medication reconciliation is widely recognized, the optimal approach to reconciling medications is yet to be determined through a consensus of empirical research. As there is no definitive method that ensures success, different health care organizations and settings have adopted varying processes for medication reconciliation. The Institute for Healthcare Improvement (IHI) suggests that a well-designed medication

reconciliation process will share the following characteristics: (a) A patient-centered approach is used; (b) The process is easy to complete for all of those involved. Staff recognize their role in the process and how it benefits them specifically; (c) The opportunity for drug interactions and therapeutic duplications is reduced by making the patient’s home list of medications available when a medication is prescribed; (d) The patient is provided with an up-to-date list of

medications; (e) Other providers who need to know have access to information about changes in the patient’s medication plan. [10]

The results of a study by Gleason and colleagues, [13] have led to other suggestions that assist health care organizations with developing medication reconciliation processes. To facilitate medication reconciliation, ensure that a single medication list, shared by all disciplines, is available in the patient’s record. Clearly define the roles and responsibilities of each discipline concerning medication reconciliation involved in the patient’s care. The

medication reconciliation process should be standardized throughout the organization and the process should be integrated into existing workflow. If possible, integrate reminders and prompts into the process, such as including a physician reminder to reconcile medications during

admission medication order entry. The medication reconciliation process must also meet all organizational policies, local laws, and regulatory requirements. [14]

Pharmacist-led Interventions

The literature does not clearly indicate which health care provider is best suited to perform medication reconciliation. Most studies have focused on interventions performed by nurses, physicians, or pharmacists or they have used a multi-disciplinary approach. However, pharmacists may be the most qualified health care providers to perform medication reconciliation and identify medication issues at transitions of care. Medication reconciliation interventions led


Haldiman – Medical Reconciliation in Patient Safety Page 4 by pharmacists have been found among the most promising methods studied that have been able to demonstrate a positive impact on clinical outcomes. [15]

A study by Gillespie and colleagues [16] demonstrated a reduction in all hospital visits by 16%, a decrease in emergency room visits by 47% and a decrease in drug-related admissions by 80% after a clinical pharmacist-led medication reconciliation intervention. The pharmacists participated in the medication reconciliation process by collecting a comprehensive list of current medications upon admission and ensuring that the receiving hospital unit had an accurate list. The pharmacist conducted a comprehensive drug regimen review and collaborated with the physician to assist with drug selection, dosages, and monitoring needs. Patients received medication education from the pharmacist throughout the admission process, as well as discharge counseling. After discharge, the pharmacist communicated information about

discharge medications to the primary care physician and performed a telephone follow-up call to the patient 60-days post-discharge. [16]

Other studies have also demonstrated the usefulness of pharmacists in the medication reconciliation process. A study by Strunk, Matson, and Steinke [17] used pharmacists to lead medication reconciliation efforts during the admission process. Results found that 2.8% of patients had an unreconciled medication after the intervention compared to 52% prior to the study (p<0.001). Hayes and colleagues [18] found that pharmacist-acquired medication histories in the emergency department had significantly fewer errors in documentation and more

documentation concerning patient allergies. A study conducted by Nester and Hale [19] found that pharmacist-acquired medication histories were more accurate than those collected by nurses. Key Components to the Medication Reconciliation Process

A culture of safety is a key factor to ensuring the success of a medication reconciliation process. A culture of safety can be defined as the existence of a blame-free healthcare environment where individuals are able to report errors or close calls without fear of punishment, everyone takes responsibility for their role in patient safety, including patients and caregivers, there is collaboration between health care providers to keep patients safe, and the organizational leadership commits resources to continually improving patient safety.[20-21] A recent study conducted by White and colleagues[22] demonstrates that establishing a culture of safety, as well as the application of quality improvement methods, can be the missing link to medication reconciliation. In this study, the hospital had already implemented electronic health


Haldiman – Medical Reconciliation in Patient Safety Page 5 records (EHRs) and a computerized provider order entry (CPOE) system without a reliable demonstration of improvement to the medication reconciliation process. Implementing a culture of safety, in which leadership demonstrated a commitment to ensuring medication safety, allowed the organization to demonstrate an improvement from 62% to greater than 90% of the number of patients who had their medications reconciled within 24 hours of admission. [22]

A culture of safety is important to medication reconciliation because buy-in and support from leadership is necessary to ensure that resources are directed toward developing and

implementing the process, as well as communicating the importance of the process to staff and patients. Staff education and training is needed to allow staff to have a thorough understanding of the process and their role in medication reconciliation. Quality improvement methods allow progress to be made more quickly and to demonstrate outcomes of reconciliation efforts to key stakeholders.

Many health care organizations have designed medication reconciliation processes to include electronic health technologies, such as EHRs and CPOE. If implemented properly, EHRs may allow for easier access to a patient’s medication history, which can assist in the medication reconciliation process. When all health care providers utilize the same EHR, the EHR is kept up-to-date, and all medications are reconciled against this record, EHRs can improve the accuracy of medication reconciliation.[23] EHRs and other technologies, such as medication bar coding and smart IV infusion pumps, can improve documentation of what medications are administered to a patient. CPOE can assist with medication reconciliation by eliminating prescribing errors due to handwriting and ensuring that key fields, including dosage, frequency, and route, are included in the prescription. Perhaps more importantly, CPOE allows for clinical decision support that suggests appropriate dosages for the patient’s clinical condition, age, and renal function and includes checks for allergies and drug-drug interactions.[2] However, with any electronic technology, its success depends upon the accuracy of the medications and information entered by the provider. Appropriate medication reconciliation by verification, clarification, and reconciliation is still necessary.

Patient and caregiver involvement in the medication reconciliation process has been shown to decrease the likelihood of experiencing a medication error.[2] To become

involved with medication reconciliation, patients or caregivers should be encouraged to keep an up-to-date list of all medications they are taking, including prescription, over-the-counter, and


Haldiman – Medical Reconciliation in Patient Safety Page 6 supplements. Patients should take the list with them to every health care encounter and ask a health care provider to review the list. In outpatient settings, patients should ask providers to provide clear information about the name of drugs that are being prescribed, the dosage, the frequency, what it is to be used for, and how to recognize side effects. At the pharmacy, patients can compare instructions given by the prescriber to that received by the pharmacist. Patients should be encouraged to review their list of medications with the pharmacist and to seek medication counseling with the pharmacist if they have any questions. In the inpatient setting, patients should ask what medications are being administered to them and the reason why they are receiving them. Prior to discharge, patients should ensure that they receive a list of medications to take once they arrive home and have a provider review it with them.[2]

Barriers to Medication Reconciliation

There are numerous challenges associated with implementing an effective medication reconciliation process across the continuum of care. A common challenge is that patients and caregivers are often unreliable sources of an accurate medication history. Patients are sometimes unaware of the medications that they are taking, as well as the dosages and frequency. Obtaining this information from outside sources, such as the primary care physician or the patient’s pharmacy, is a complex process for which health care provider may not have the time to devote. The lack of time that health care providers have to focus on medication

reconciliation is also a barrier itself. Accurate medication reconciliation does involve a time commitment and the workload and time demands of health care provider may not always be conducive to completing this process accurately. [10, 24]

An organizational culture that does not value medication safety is another barrier to medication reconciliation. [2] A culture of safety is critical to ensuring that the organization, its leaders, and employees value medication reconciliation, understand the importance of performing the process, and allocate resources to ensuring it is successful. Similarly, a lack of accountability for medication reconciliation may result in the process not being completed accurately. [10] A lack of standardization in the process is another challenge that contributes to erroneous medication reconciliation. When the process is not standardized, health care providers are often confused about when medication reconciliation needs to be performed and who should perform it. [10]


Haldiman – Medical Reconciliation in Patient Safety Page 7

Overcoming Medication Reconciliation Challenges

Clearly defining the roles and responsibilities of health care providers can be helpful in ensuring that the medication reconciliation process is performed accurately and work is not duplicated.[10,23] To assist in developing a culture of medication safety, a medication reconciliation champion should be identified.[24] This individual should be well-respected within the organization and his/her role is to model ideal behavior regarding medication reconciliation and assist in educating colleagues about the importance of the process and the proper way to perform it. Appropriate training and education of staff regarding the medication reconciliation process is also a key element to overcoming challenges. [10, 23] Patient education about their medications and their role in medication reconciliation serves as a mitigating factor in overcoming barriers related to patient lack of knowledge. [23]

Standardization of the medication reconciliation process is necessary in order to ensure success. A standard form to assist with medication reconciliation should be utilized. There are numerous examples of these forms available for use by the IHI and TJC. [10, 11] However, it is important to remember that medication reconciliation is not only about completing a form, but it is a three-step process of verification, clarification, and reconciliation. As part of the standardized process, there should be a time frame specified for when medication

reconciliation must occur. For example, a health care organization may implement a policy that calls for medication reconciliation at every primary care visit and within 24 hours of an inpatient admission. It is also important that the medication reconciliation process is monitored to ensure compliance. [23] The use of process improvement methodologies will allow for continuous evaluation and refinement of the medication reconciliation process to allow for improved patient outcomes.


The American Society of Health-Systems Pharmacists’ 2015 Initiative [25] includes actions that improve pharmacy practice within health care systems. With five of the six goals related to the extent that pharmacists can increase their involvement in improving patient medication safety and ensuring the best use of medications, pharmacists’ role in medication reconciliation is clearly supported. As pharmacists become more involved with medication reconciliation, health care organizations may find it easier to achieve regulatory requirements set forth by organizations such as TJC.


Haldiman – Medical Reconciliation in Patient Safety Page 8 Medication reconciliation is a three-step process of verification, clarification, and reconciliation that improves patient safety by ensuring that patients are receiving and taking the correct medications. Research has demonstrated that pharmacists should play a lead role in the medication reconciliation process because they are well-equipped to perform an accurate and complete medication history and provide effective patient education regarding medications. Although there are barriers to effective medication reconciliation, there are also proven methods of overcoming challenges. As research continues to demonstrate the benefit of including

pharmacists in the medication reconciliation process, pharmacists may have an increased scope of responsibility with the process.


Haldiman – Medical Reconciliation in Patient Safety Page 9


1. Veterans’ Administration Center for Medication Safety. (2006). Adverse drug events, adverse drug reactions, and medication errors. Retrieved May 15, 2010 from


2. Aspden, P., Wolcott, J. Bootman, J.L., & Cronenwett. L.R. (Eds). (2006). Preventing medication errors: Quality chasm series. Washington, D.C.: Committee on Identifying and Preventing Medication Errors, Institute of Medicine, National Academies Press.

3. Kohn, L.T., Corrigan, J.M, & Donaldson, M.S. (Eds.). (1999). To err is human: Building a safer health system. Washington, D.C.: Committee on Quality of Health Care in America, Institute of Medicine, National Academies Press.

4. Agency for Healthcare Research and Quality (AHRQ). (2001). Reducing and preventing adverse drug events to reduce hospital costs. Research in Action, 1 (AHRQ Publication No. 01-0020). Rockville, MD: AHRQ.

5. Massachusetts Technology Collaborative (MTC) and the New England Healthcare Institute (NEHI). (2008). Saving lives, saving money: The imperative CPOE in Massachusetts. Retrieved May 19, 2011 from

http://www.nehi.net/publications/8/saving_lives_saving_money_the_imperative_for_computeriz ed_physician_order_entry_in_massachusetts_hospitals.

6. Center of Information Technology Leadership (CITL). (2007). The value of computerized physician order entry in ambulatory settings. Retrieved May 19, 2011 from


7. Rozich, J.D. & Resar, R.K. (2001). Medication safety: One organization’s approach to the challenge. Journal of Clinical Outcomes Management, 8(10), 27 – 34.

8. Cornish, P.L., Knowles, S.R., Marchesano, R., Tam, V., Shadowitz, S., Juurlink, D.N. et al. (2005). Unintended medication discrepancies at the time of hospital admission. Archives of Internal Medicine, 165(4), 424 – 429.

9. Whittington, J. & Cohen, H. (2004). OSF’s healthcare journey in patient safety. Quality Management in Healthcare, 13(1), 53 – 59.

10. Institute for Healthcare Improvement (IHI). (2008). Getting started kit: Prevent adverse drug events (medication reconciliation how-to guide). Cambridge, MA: IHI.


Haldiman – Medical Reconciliation in Patient Safety Page 10 11. The Joint Commission (TJC). (2010). Summary of sentinel events reviewed by the Joint

Commission. Retrieved May 24, 2011from

http://www.jointcommission.org/assets/1/18/SE_Data_Summary_4Q_2010_(v2).pdf. 12. The Joint Commission (TJC). (2010). National patient safety goal on reconciling medication

information. Retrieved May 22, 2011 from


13. Gleason, K.M., McDaniel, M.R., Feinglass, J., Baker, D.W., Lindquist, L., Liss, D. et al. (2010). Results of the medications at transitions and clinical handoffs (MATCH) study: An analysis of medication reconciliation errors and risk factors at hospital admission. Journal of General Internal Medicine, 25(5), 441 – 447.

14. Northwestern Memorial Hospital. (2011). MATCH- Medication reconciliation toolkit. Retrieved June 3, 2011 from

http://www.nmh.org/nm/medication+reconciliation+toolkit+design+process+part+one. 15. Agency for Healthcare Research and Quality (AHRQ). (no date). Medication reconciliation.

Retrieved June 3, 2011 from http://www.psnet.ahrq.gov/primer.aspx?primerID=1.

16. Gillespie, U., Alassaad, A., Henrohn, D., Garmo, H., Hammarlund-Udenaes, M., Toss, H. et al. (2009). A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older. Archives of Internal Medicine, 169(90), 894 – 900.

17. Strunck, L.B., Matson, A.W., & Steinke, D. (2008). Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs medical center. Hospital Pharmacy, 43(8), 643 – 649.

18. Hayes, B.D., Donovan, J.L., Smith, B.S., and Hartman, C.A. (2006). Pharmacist-conducted medication reconciliation in the emergency department. American Journal of Health-System Pharmacy, 64(16), 1720 – 1723.

19. Nester, T.M. & Hale, L.S. (2002). Effectiveness of a pharmacist-acquired medication history in promoting patient safety. American Journal of Health-System Pharmacy, 59(22), 2221 – 2225. 20. Institute for Healthcare Improvement (IHI). (no date). Developing a culture of safety. Retrieved May

22, 2011 from

http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Develop+a+Culture+o f+Safety.htm.


Haldiman – Medical Reconciliation in Patient Safety Page 11 2011 from http://psnet.ahrq.gov/primer.aspx?primerID=5.

22. White, C.M., Schoettker, P.J., Conway, P.H., Geiser, M., Olivea, J., Pruett, R. et al. (2011). Utilising improvement science methods to optimize medication reconciliation. BMJ Quality and Safety, 20(1), 372 – 380.

23. Barnsteiner, J.H. (2008). Medication reconciliation. In Hughes, R.G. (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality.

24. Mitryzk, B.M. & Ganatra, S. (2009). Conducting medication reconciliation in various patient settings. Michigan Pharmacists, 47(3), 17 – 22.


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