Medication Reconciliation

Brian J. Clay, MD, SFHM*, Jennifer Quartarolo, MD, SFHM

KEYWORDS
 Medication reconciliation  Medication management  Clinical informatics
 Transitions of care  Patient safety

HOSPITAL MEDICINE CLINICS CHECKLIST

1. Medication reconciliation is the process of obtaining and maintaining a patients

medication list at every transition of care, and using this information when
writing new medication orders or prescriptions for the patient.
2. Lack of reconciliation can lead to adverse drug events (ADEs), emergency
department visits, and rehospitalizations. Up to 20% of medication errors dur-
ing transitions of care lead to patient harm.
3. Reliable medication reconciliation processes can reduce ADEs and health care
resource use. Using pharmacist resources to provide reconciliation for high-risk
patient groups may be the most effective way to improve outcomes.
4. Medication reconciliation involves verification of a patients medication infor-
mation, clarifying any potential discrepancies, and documenting (reconciling)
any changes to the medication information.
5. Medication reconciliation work flow requirements are more streamlined for
ambulatory clinic and emergency department settings compared with the hos-
pital setting.
6. Although many hospitals began with a paper-based medication reconciliation
work flow, most electronic medical records (EMR) applications have medication
reconciliation functionality, and EMR implementation in hospitals is becoming
the norm.
7. Physicians, nurses, and pharmacists may participate in medication reconcilia-
tion; individual institutions have the responsibility for establishing their work
flows.

CONTINUED

Disclosures: Drs Clay and Quartarolo have no funding sources or conflicts of interest to disclose.
Division of Hospital Medicine, University of California San Diego Health System, 200 West
Arbor Drive, Mail Code 8485, San Diego, CA 92103, USA
* Corresponding author.
E-mail address: bclay@ucsd.edu

Hosp Med Clin 2 (2013) e472e480

http://dx.doi.org/10.1016/j.ehmc.2013.02.005
2211-5943/13/$ see front matter 2013 Elsevier Inc. All rights reserved.

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 Medication Reconciliation e473

CONTINUED
8. Overly complex processes and lack of clarity regarding lines of responsibility for
performing reconciliation can hinder successful implementation.
9. There are multiple online resources for medication reconciliation best-practice
standards and implementation tool kits.

KEY PRINCIPLES

1. What is medication reconciliation?

Definition of Medication Reconciliation

The concept of medication reconciliation was first introduced to the broader medical
community in 2005, when the Joint Commission established it as a National Patient
Safety Goal (NPSG) for hospitals. The definition outlined in the NPSG has evolved
over time1:
 2005 definition: Completely and accurately reconcile medications throughout
the continuum of care.
 2011 definition: Maintain and communicate accurate patient medication
information.
One of the best operational definitions was established by an expert panel
convened by the American Society of Health System Pharmacists (ASHP) and the
American Pharmacy Association (APhA) in 20072:

Medication reconciliation is the comprehensive evaluation of a patients medica-

tion regimen any time there is a change in therapy in an effort to avoid medication
errors such as omissions, duplications, dosing errors, or drug interactions, as well
as to observe compliance and adherence patterns. This process should include a
comparison of the existing and previous medication regimens and should occur at
every transition of care in which new medications are ordered, existing orders are
rewritten or adjusted, or if the patient has added nonprescription medications to
[his or her] self-care.

A medication reconciliation process is therefore a more comprehensive version of a

medication history. The process involves:
 Maintenance of accurate medication information for a patient
 Use of that information when new medication orders or prescriptions are written
 Communication of medication information changes to the patient when
appropriate
From the perspective of a hospitalist, medication reconciliation is a process for
comparing a patients current medications with the medications ordered for the pa-
tient, whether at admission, transfer, or discharge.
Definition of Medications
Implicit in having a definition for medication reconciliation is the need for a definition of
medication. According to the Joint Commission,3 medications include:
 Prescription medications
 Over-the-counter medications

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e474 Clay & Quartarolo

 Vitamins, nutraceuticals, and herbal preparations

 Parenteral nutrition
 Intravenous solutions (plain, or containing electrolytes or drugs)
Supplemental oxygen and enteral nutrition solutions are excluded. Any medications
or other preparations taken on an as-needed basis are included.

2. What are the patient safety implications when medication reconciliation does not
occur?
When medication information is not reliably obtained or maintained, then patients can
experience adverse outcomes, including adverse drug events (ADEs), emergency
department visits, increased length of stay, and increased risk of readmission. Transi-
tions of care such as hospital admission and discharge are particularly prone to medi-
cation error risk. It is estimated that up to 40% of medication errors occur at points of
transitions of care, and that up to 20% of these errors result in patient harm.4,5 ADEs
cause 2.5% of emergency department visits for unintentional injuries, and 6.7% of
hospitalizations related to such visits.6
Multiple studies have shown that inaccurate medication lists are common among
hospitalized patients, particularly at the time of hospital admission and discharge.
Literature reviews have shown that 30% to 70% of patients medication lists at the
time of hospital admission contain discrepancies.7 Errors on the admission medication
list are the most common cause of ADEs related to discrepancies and may be prop-
agated throughout the continuum of care.7

3. What are the known impacts of improving medication reconciliation in hospitalized

patients in particular?
There are few large, multicenter studies of the specific elements of medication recon-
ciliation interventions that most effectively decrease errors and improve clinical out-
comes. A recent systematic review highlighted evidence that pharmacy staff
involvement in the process decreases ADEs and health care use8; ASHP supports
this position as well.2 Information technology solutions may also decrease discrep-
ancies and potentially reduce ADEs. Focusing more intensive interventions on higher
risk groups (eg, elderly patients, patients with polypharmacy) may have a greater
impact on outcomes.

GUIDELINES FOR PRACTICE

4. What are the relevant operational aspects of medication reconciliation for

hospitalists?
The Institute for Healthcare Improvement considers all medication reconciliation pro-
cesses to consist of 3 basic steps9:
 Verification: collecting the medication information from the patient and/or ancil-
lary sources
 Clarification: ensuring that the medications, doses, and indications are
appropriate
 Reconciliation: documentation of changes in the medication orders
The practicing hospitalist sees these three steps manifested in the basic transitions
of care in the inpatient setting.10

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 Medication Reconciliation e475

Hospital Admission
A patients outpatient medication information should be obtained and confirmed with
the patient and/or ancillary sources, and a list documented in the medical record. This
medication list should be used as a source of information when writing orders for
medications to be administered in the inpatient setting.

Hospital Unit-to-Unit Transfer

When transferring a patient between levels of care, the current medication list is the list of
active inpatient medication orders. Again, this list should be reviewed for medications that
need to be continued, adjusted, or discontinued on transfer to the next level of care. In
addition, revisitation of the outpatient medication list is appropriate to determine whether
any of the medications the patient was on before admission should now be restarted.

Hospital Discharge
As with hospital transfer, the current list of active inpatient medication orders should
be reviewed for any medications that need to be prescribed for outpatient use
following discharge. In addition, revisitation of the prior-to-admission outpatient medi-
cation should be done, to determine whether any of these medications need to be
refilled, adjusted, or discontinued. In addition, because the patient is leaving the hos-
pital with the medication list likely having been changed, a new updated medication
list should be provided to the patient on discharge.

5. What are the relevant operational aspects of medication reconciliation for ambula-
tory and emergency medicine providers, and what impact do they have on
hospitalists?

Because patients in the outpatient clinic or in the emergency department do not have
admission medication orders written for ongoing medication administration in those
settings, the requirements are more straightforward.
In these settings,11 the requirements are to:
 Collect and verify the patients current medication information
 Provide the patient with an updated list of medications if any changes are made
during the visit (if the only change is the addition of short-term medications, such
as a course of antibiotics, only the new medication information must be provided
to the patient)
When patients are unable to provide their own medication information at the time of
hospital admission, providers must often rely on outpatient medication information
from the patients clinic or from a previous emergency department visit.

6. How have hospitals generally implemented medication reconciliation work flows?

The implementation of medication reconciliation processes since 2005 has coincided
with the move toward implementation of electronic medical record (EMR) systems.
Many institutions began with a paper-based process and then moved to an electronic
process as EMR systems with computerized-provider order entry (CPOE) became
available.

Hospital Admission
A common historical work flow at admission was to list the outpatient medications
within the history and physical note, and to write admission orders on another form.

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e476 Clay & Quartarolo

A key work flow step for a paper-based medication reconciliation process was for
hospitals to allow documentation of the home medication list and the inpatient orders
to continue any home medications on the same form. Many such forms are available
online; ASHP has some examples on their Web site.12
Most EMR applications replicate this efficiency, and allow for inpatient ordering
directly from a documented outpatient medication list. It is also common for EMR
applications to allow for modification of, or substitution for, the home medication at
the time of inpatient ordering, rather than just continuing the medication with the
same dose and frequency.
When patients have ambulatory care information in the same EMR as the hospital,
the existing medication information is usually present for modification and use.

Hospital Unit-to-Unit Transfer

Because paper-based inpatient transfer work flows often involve writing a new set of
active orders for the patient, medication reconciliation at transfer in these settings re-
mains inefficient. The home medications and the currently active inpatient medication
orders should be reviewed by the provider as new transfer orders are being written.
In contrast, EMR applications usually allow for continuation, modification, or discon-
tinuation of the active inpatient medication orders as part of the inpatient transfer work
flow. Some applications also show the home medication list during inpatient transfer
to allow for the opportunity to re-start any home medications that were initially not
continued at the time of admission.

Hospital Discharge
Creating a single paper form for discharge medication reconciliation is challenging for
several reasons:
 The patient needs to receive an updated list of medications on discharge, which
should avoid abbreviations and shorthand used in writing prescriptions.
 State laws often require particular elements on forms for them to work as pre-
scription forms.
 Making modifications to home medications, such as increasing a dose, is difficult
to do clearly on a paper form.
 Patients may take many medications, requiring more than one form to list all of
the medications.
Because of this complexity, hospitals with paper-based work flows often cannot
use a single form for prescribing, reconciliation, and for patient use.
EMR applications usually incorporate any actions on the home medication list, the
inpatient active medication orders, and new medication prescription information into a
single medication list for the patient at the time of discharge.
Even with an EMR in place at the hospital, patients may not receive their ambulatory
care at the same institution. For this reason, giving a single medication list to the
patient at the time of discharge is a key step.

7. What are some common operational questions related to implementing medication

reconciliation?
In 2005 and 2006, the elements of performance (EPs) for the Joint Commission NPSG
for medication reconciliation were detailed and prescriptive, leading to poor imple-
mentation of processes by hospitals. In 2009, the NPSG was revised by the Joint
Commission with this in mind.

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 Medication Reconciliation e477

The current EPs for the 2012 medication reconciliation NPSG for hospital settings
provide more general guidance11:

 Obtain information on the medications that patients are currently taking when
they are admitted to the hospital. This information is documented in a list or other
format that is useful to those who manage medications.
 Define the types of medication information to be collected.
 Compare the medication information the patient brought to the hospital with the
medications ordered for the patient in the hospital to identify and resolve
discrepancies.
 Provide the patient (or family, as needed) with written information on the medica-
tions the patient should be taking when discharged from the hospital.
 Explain the importance of managing medication information to patients when
they are discharged from the hospital.
Because the current NPSG provides only general parameters for hospitals, common
questions arise regarding specifics.

Is a dedicated form required for medication reconciliation?

The current iteration of the NSPG suggests that a dedicated form is strongly recom-
mended. The format of listing the medications in free-text form in the history and phys-
ical note is not a useful format in terms of facilitating inpatient ordering of home
medications. EMR applications usually provide a dedicated section to document
the home medications in a structured fashion.

Must a physician be the one who performs medication reconciliation?

The NSPG does not specify what types of health care personnel must perform medi-
cation reconciliation. Hospitals have used physicians, nurses, and occasionally phar-
macists in combination to perform these tasks.13 The Joint Commission only requires
that a qualified individual perform medication reconciliation.11 There are several pub-
lished studies indicating that pharmacist involvement for high-risk patients at the time
of admission can reduce medication errors.2

Are physicians required to reconcile medications prescribed by specialists?

Some providers are reluctant to make decisions about medications with which they
are not familiar. However, in terms of documenting the home medication list, the
admitting provider is still responsible for listing what medications the patient is taking.
If there is uncertainty about whether a patient should continue a specific medication in
the hospital, or whether it should be resumed on discharge, then the appropriate
specialty consultation should be made.

What detail of medication information needs to be collected and documented?

Although the Joint Commission does not specify a minimum standard, the NSPG
suggests that medication information should include name, dose, route, and fre-
quency. Indication for the medication and time of last dose taken are additional
data points that can be considered for documentation. Hospital policies on medica-
tion reconciliation should provide guidance to their physicians as to what is required
locally.

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e478 Clay & Quartarolo

What are the discrepancies that medication reconciliation is intended to resolve?

Per the NPSG, discrepancies include omissions, duplications, contraindications, and
unclear information.11 Care should also be taken to ensure that obsolete medications
are removed from the list.

What if patients do not know their medication information?

The NPSG instructs providers to make a good faith effort to obtain the best medication
list possible at the time of admission, and to use family members, caregivers, and ancil-
lary sources if possible. Any documentation format of the home medication list should
include opportunities to document inability to obtain medication information because of
specific clinical situations (eg, patient has confusion or decreased mental status).

Is the discharging provider required to communicate a discharge medication list to the

primary care physician?
The 2006 version of the NPSG included a requirement for communicating the
discharge medication list to the next provider of care. However, because many pa-
tients do not have access to regular outpatient management, this requirement was
removed in 2009. The NPSG now requires only that a medication list is given to the
patient at the time of discharge.

What does Explain the importance of managing medications mean?

Because EMR systems between medical practices and hospitals are not seamlessly
integrated, it is not yet easy to share medication information directly between institu-
tions. Therefore, patients should be encouraged to always carry a medication list with
them, and to review and update it with their physicians at each clinical encounter. A
recent study showed that patients who maintain an up-to-date personal health record
experience fewer medication errors.14

8. What are some of the common pitfalls in medication reconciliation work flows?
Some of the common pitfalls are inherent in the complexity of the medication manage-
ment process:
 Patients receiving medication management in multiple disparate systems
 Patients providing incomplete medication information (eg, name of medication only)
 Providers neglecting to ask about over-the-counter medications and herbal
preparations
 Providers neglecting to list as-needed medications
 Amount of time required to access ancillary sources for medication information
when the patient is unsure about specifics
 Confusion about how to reconcile medications with complex administration reg-
imens (eg, tapered medications)
 State requirements for special prescription paper for controlled substances,
requiring these medications to be handled differently than other medications
Other pitfalls arise from the systems put in place to perform medication
reconciliation:
 Use of paper forms leading to illegible medication entries and medication errors
 Overly complex forms

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 Medication Reconciliation e479

 Lack of clarity regarding who is responsible for performing various steps of the
process
 Persistence of obsolete medication orders in EMR systems
 Difficulty with using complex medication reconciliation tools in EMR systems
For these and similar reasons, it is likely that dedicated pharmacist support in medi-
cation reconciliation for high-risk or complex patients significantly reduces errors. In
any event, targeted process training of providers who perform medication reconcilia-
tion is advised. Several examples of training to the best possible medication history
are available online.15,16

9. What are some of the unresolved questions regarding medication reconciliation?

The streamlined EPs that were put into place with the 2009 version of the NPSG have
been helpful in improving implementation of reconciliation processes by hospitals.
However, some questions remain:
 Will there be a regulatory standard as to what level of medication information
must be documented?
 Will there be a regulatory standard as to what type of health care provider (eg,
physician, pharmacist) must perform certain tasks in medication reconciliation?
 How can medication information from multiple clinics and hospitals be seam-
lessly integrated to assist the reconciliation process?
 How can medication dispensing information from pharmacies be queried or inte-
grated to assist the reconciliation process?
 Can substantially improved medication reconciliation significantly reduce hospi-
tal readmissions?
Further research on medication reconciliation processes is warranted, especially as
EMR systems become more and more prevalent in hospitals.

10. Where can best-practice standards for medication reconciliation be located?

 The Institute for Healthcare Improvement has published a How-to guide for
implementation.9
 The Agency for Healthcare Research and Quality has published its Medications
at Transitions and Clinical Handoffs tool kit online.17
 The National Quality Forum has published a list of quality measures for med-
ication reconciliation for those institutions that need metrics for quality-
improvement purposes.18
 ASHP and APhA have published their best-practice recommendations.2
 The Society of Hospital Medicine has made available a quality-improvement
resource room with background information and multiple tools to assist in imple-
mentation and quality improvement on this topic.19

REFERENCES

1. The Joint Commission. Approved: modifications to National Patient Safety Goal

on reconciling medication information. Jt Comm Perspect 2011;31(1):1.
2. Chen D, Burns A. Summary and recommendations of ASHP-APhA Medication
Reconciliation Initiative Workgroup Meeting, February 12, 2007. Available at: http://
www.ashp.org/s_ashp/docs/files/MedRec_ASHP_APhA_Wkgrp_MtgSummary.pdf.
Accessed October 15, 2012.

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e480 Clay & Quartarolo

3. The Joint Commission. 2010 comprehensive accreditation manual for hospitals:

the official handbook. Oak Brook (IL): Joint Commission Resources; 2009 [GL-19].
4. Barnsteiner JH. Medication reconciliation: transfer of medication information
across settingskeeping it free from error. J Infus Nurs 2005;28(Suppl 2):316.
5. Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in
medication histories and admission orders of newly hospitalized patients. Am J
Health Syst Pharm 2004;61:168995.
6. Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emer-
gency department visits for outpatient adverse drug events. JAMA 2006;296:
185866.
7. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrep-
ancies at the time of hospital admission. Arch Intern Med 2005;165:4249.
8. Mueller SK, Sponsler KC, Kripalani S. Hospital-based medication reconciliation
practices. Arch Intern Med 2012;172(14):105769.
9. Institute for Healthcare Improvement: protecting 5 million lives from harm: getting
started kit: prevent adverse drug events (medication reconciliation)How-to guide.
Available at: http://www.ihi.org/IHI/Programs/Campaign/ADEsMedReconciliation.
htm. Accessed October 15, 2012.
10. Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication recon-
ciliation patient centered, clinically relevant and implementable: a consensus
statement on key principles and necessary first steps. J Hosp Med 2010;8:
47785.
11. The Joint Commission. 2013 National patient safety goals. Available at: http://www.
jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf. Accessed
October 15, 2012.
12. American Society of Health-System Pharmacists. Medication reconciliation ba-
sics. Available at: http://www.ashp.org/Import/PRACTICEANDPOLICY/Practice
ResourceCenters/PatientSafety/ASHPMedicationReconciliationToolkit_1/
MedicationReconciliationBasics.aspx#. Accessed October 15, 2012.
13. Clay BJ, Halasyamani L, Stucky ER, et al. Results of a medication reconciliation
survey from the 2006 Society of Hospital Medicine national meeting. J Hosp Med
2008;3(6):46572.
14. Schnipper JL, Gandhi TK, Wald JS, et al. Effects of a personal health record on
medication accuracy and safety: a cluster-randomized trial. J Am Med Inform
Assoc 2012;19(5):72834.
15. Queens University. Medication reconciliation: a learning guide. Available at: http://
meds.queensu.ca/courses/assets/modules/mr/4.html. Accessed November 1,
2012.
16. Institute for Safe Medication Practices Canada. Medication reconciliation. Avail-
able at: http://www.ismp-canada.org/medrec/. Accessed November 1, 2012.
17. Agency for Healthcare Research and Quality. Medications at Transitions and Clin-
ical Handoffs (MATCH) toolkit for medication reconciliation. Available at: http://
www.ahrq.gov/qual/match/match.pdf. Accessed October 15, 2012.
18. National Quality Forum. NQF endorsed patient safety measures. Available at: http://
www.qualityforum.org/Topics/Overview_Of_Safety_Measures.aspx. Accessed
October 15, 2012.
19. Society of Hospital Medicine. Medication reconciliation quality improvement resource
room. Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/
QualityImprovement/QIResourceRooms2/MARQUIS/Medication_Reconcili.htm. Ac-
cessed October 15, 2012.

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