Patient Safety Tip of the Week

October 23, 2007    

Medication Reconciliation Tools


Medication reconciliation is one of the most important patient safety activities that should be undertaken at virtually all levels of the healthcare system. The current Joint Commission standards under National Patient Safety Goals are:

Goal 8 Accurately and completely reconcile medications across the continuum of care.

·        8A There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.

·        8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.

But first quarter compliance data for 2007 show hospitals barely at 80% compliance.


On admission, unintended discrepancies between medications the patient had been taking prior to admission and those ordered on admission typically occur in the 50-60% of cases. And after discharge from the hospital, around 20% of patients suffer an adverse event, most often related to medication issues. Failures in communication and hand-offs are one of the primary reasons for such adverse events that are potentially preventable. And, though the exact frequency is not known, discrepancies during transitions and transfers between various hospital services or levels of care are common and potentially very harmful.


But success stories are becoming more numerous each day. Experiences in Massachusetts and Canada have demonstrated that such medication errors may be reduced 70-90% by the medication reconciliation process.


Not only are patients being spared the morbidity, mortality, and inconvenience due to such potentially preventable medication errors but healthcare systems are beginning to note a positive impact as well. While there is an upfront investment of time in the medication reconciliation process, successful programs have noted a significant reduction in rework and a net savings in time spent by nurses, surgeons and other physicians, and pharmacists. Well-designed forms, whether paper-based or electronic, seem to be particularly well-received by physicians because they save time and improve accuracy.


There is often an economic impact as well: hospitals, patients, and third party payors avoid the costs of medications that are no longer necessary. For example, one of the more frequent problems we see is that of patients being started on prophylactic proton pump inhibitors during a hospital stay and then being inadvertently continued on these long after the need has resolved. A good medication reconciliation process identifies this issue and corrects it in a timely fashion.


Some excellent tools for medication reconciliation programs are readily available. These include:

·          WHO Collaborative Centre for Patient Safety Solutions - Solution6

·          IHI 100,00 Lives Campaign and 5 Million Lives Campaign Toolkit

·         Massachusetts Coalition for The Prevention of Medical Errors, which includes both a toolkit  and a patient MedList

·         Canadian “Safer Healthcare Now! Campaign”


One of the most useful tools we have come across is the Getting Started Kit from the Canadian “Safer Healthcare Now! Campaign”. This toolkit was updated in 2007 after many participating Canadian hospitals had extensive experience with it. Not only does the toolkit have a wealth of sample forms for use at each transition of care, but it also has outstanding recommendations for implementation, auditing, and measurement, plus tips for improving the accuracy of information about medications the patient was taking prior to admission. It also has a great reference section, including links to sites of many other organizations having tools, forms, and educational presentations.


The key to the entire reconciliation process is getting the most accurate possible list of medications at admission. Getting a complete and accurate list of medications that a patient is taking is very difficult in our fragmented health care system. The primary care physician usually has the most comprehensive list, but even then, the PCP may not be aware of all medications prescribed, altered or discontinued by specialists.


Third party payors or pharmacy benefit managers (PBM’s) often actually have the most up-to-date data on which prescriptions are actually being filled by the patient. Because of formulary issues and adjudication issues, most pharmacy claims come in to managed care organizations very promptly. Thus, the managed care organizations have a virtual real-time snapshot of the medication profile. Several collaborative community projects are attempting to share such information through their regional health information organizations (RHIO’s). Even if your community has not developed such a RHIO, your organization should be insisting in its contracts with managed care organizations that they provide electronic access to those real-time databases to facilitate the medication reconciliation process. After all, helping to ensure accurate reconciliation benefits the managed care organizations in the long run. But even then, over-the-counter medications and free samples usually are not listed in such databases and the databases often do not contain (at least promptly) claims related to medications administered in physician offices, such as biological drugs.


And patients themselves may not be the most reliable source of information about medications. A study in this month’s Journal of General Internal Medicine found that over 30% patients thought to have good health literacy and almost 60% of those thought to have poor health literacy could not name any of their antihypertensive medications1. Involving the family or caregiver and actually bringing in the medications from home may be very helpful in the medication reconciliation process.


The bottom line is that whatever process you develop to create your Best Possible Medication History (BPMH) should rely upon multiple data sources and require diligent cross-checking.


And a last comment is that many of the available medication reconciliation forms that are currently in use lack a field to clarify the indication for which the medication was prescribed. Knowing the indication is extremely important in avoiding look-alike/sound-alike medication errors. Many medications (eg. beta-blockers) also may have several indications and you need to know which one applies to your patient. And the dosage of the medication may vary depending upon the indication for use. Similarly, most medication forms and lists fail to include reason for discontinuation. It is important to know if a medication was discontinued because of lack of efficacy, side effect, allergy, or formulary or economic reasons.



1Persell SD, Osborn CY, Richard R, Skripkauskas S, Wolf MS. Limited Health Literacy is a Barrier to Medication Reconciliation in Ambulatory Care. Journal of General Internal Medicine 2007; 22: 1523-1526




Updates: See also May 13, 2008 Patient Safety Tip of the Week “Medication Reconciliation: Topical and Compounded Medications” and our December 30, 2008 Patient Safety Tip of the Week Print “Unintended Consequences: Is Medication Reconciliation Next?” and our September 8, 2009 Patient Safety Tip of the Week “Barriers to Medication Reconciliation








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