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Medication Reconciliation
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Background

Patients admitted to a hospital commonly receive new medications or have changes made to their existing medications. Hospital-based clinicians also may not be able to easily access patients’ complete medication lists, or may be unaware of recent medication changes. As a result, the new medication regimen prescribed at the time of discharge may inadvertently omit needed medications, unnecessarily duplicate existing therapies, or contain incorrect dosages.

Such unintended inconsistencies in medication regimens may occur at any point of transition in care (e.g., transfer from an intensive care unit to a general ward), as well as at hospital admission or discharge. Studies have shown that unintended medication discrepancies occur in nearly one-third of patients at admission, a similar proportion at the time of transfer from one site of care within a hospital, and in 14% of patients at hospital discharge. Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care. Though most often discussed in the hospital context, medication reconciliation can be equally important in ambulatory care, as many patients receive prescriptions from more than one outpatient provider.

More than half of patients have ≥ 1 unintended medication discrepancy at hospital admission. 61% of these discrepancies had no harm potential; 33% had moderate harm potential; and 6% had severe harm potential.

Source: Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429. [go to PubMed]

Accomplishing Medication Reconciliation

The evidence supporting patient benefits from reconciling medications is relatively scanty. A 2012 systematic review of 26 inpatient medication reconciliation studies did find some evidence supporting pharmacist-led medication reconciliation processes, but overall, no conclusions could be reached regarding the most effective or generalizable strategies. Although information technology solutions are being widely studied and appear to significantly reduce medication discrepancies, their effect on clinical outcomes remains unclear.

The evidence supporting patient benefits from reconciling medications is relatively scanty. Interventions led by pharmacists may be the most promising, as at least one study utilizing a pharmacist-led medication reconciliation process at discharge did improve clinical outcomes, and other studies have shown reductions in actual and potential medication errors. While information technology solutions are being widely studied, and do appear to significantly reduce medication discrepancies, their effect on clinical outcomes remains unclear.

Current Context

Medication reconciliation was named as 2005 National Patient Safety Goal #8 by the Joint Commission. The Joint Commission's announcement called on organizations to "accurately and completely reconcile medications across the continuum of care." In 2006, accredited organizations were required to "implement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient" and to communicate "a complete list of the patient's medications…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 Joint Commission suspended scoring of medication reconciliation during on-site accreditation surveys between 2009 and 2011. This policy change was made in recognition of the lack of proven strategies for accomplishing medication reconciliation. As of July 2011, medication reconciliation has been incorporated into National Patient Safety Goal #3, "Improving the safety of using medications." This National Patient Safety Goal requires that organizations "maintain and communicate accurate medication information" and "compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies."

 
What's New in Medication Reconciliation on AHRQ PSNet
TOOLS/TOOLKIT
My Medicines.
Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association of Chain Drug Stores.
NEWSPAPER/MAGAZINE ARTICLE
Health-care providers want patients to read medical records, spot errors.
Landro L. Wall Street Journal. June 9, 2014.
STUDY
Patient, physician, medical assistant, and office visit factors associated with medication list agreement.
Reedy AB, Yeh JY, Nowacki AS, Hickner J. J Patient Saf. 2014 Mar 18; [Epub ahead of print].
 
Editor's Picks for Medication Reconciliation
From AHRQ WebM&M
Medication Reconciliation Victory after an Avoidable Error.
Timothy W. Cutler, PharmD. AHRQ WebM&M [serial online]. February/March 2009
Hospital Admission Due to High-Dose Methotrexate Drug Interaction.
Lydia C. Siegel, MD; Tejal K. Gandhi, MD, MPH. AHRQ WebM&M [serial online]. January 2009
Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work?.
Josh Peterson, MD, MPH. AHRQ WebM&M [serial online]. May 2008
Medication Reconciliation: Whose Job Is It?
Eric G. Poon, MD, MPH. AHRQ WebM&M [serial online]. September 2007
Reconciling Doses.
Frank Federico, RPh. AHRQ WebM&M [serial online]. November 2005
Medication Reconciliation Pitfalls.
Robert J. Weber, PharmD, MS. AHRQ WebM&M [serial online]. February 2010
Reconciling Records.
Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH. AHRQ WebM&M [serial online]. November 2010
 
From AHRQ PSNet
JOURNAL ARTICLE
The incidence and severity of adverse events affecting patients after discharge from the hospital. Classic icon
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003;138:161-167.
Role of pharmacist counseling in preventing adverse drug events after hospitalization. Classic icon
Schnipper JL, Kirwin JL, Cotugno MC, et al. Arch Intern Med. 2006;166:565-571.
Hospital-based medication reconciliation practices: a systematic review. Classic icon
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Arch Intern Med. 2012;172:1057-1069.
Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. Classic icon
Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-847.
Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.
Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. CMAJ. 2005;173:510-515.
Unintended medication discrepancies at the time of hospital admission. Classic icon
Cornish PL, Knowles SR, Marchesano R, et al. Arch Intern Med. 2005;165:424-429.
Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Classic icon
Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-780.
A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial.
Gillespie U, Alassaad A, Henrohn D, et al. Arch Intern Med. 2009;169:894-900.
TOOLS/TOOLKIT
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.
Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.
Safety Information for Patients and Families.
The Massachusetts Coalition for the Prevention of Medical Errors.
WEB RESOURCE
National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; 2013.
LEGISLATION/REGULATION
Using medication reconciliation to prevent errors.
Sentinel Event Alert. January 25, 2006;(35):1-4.
NEWSPAPER/MAGAZINE ARTICLE
What drugs do you take? Hospitals seek to collect better data and prevent errors.
Landro L. Wall Street Journal (Eastern edition). May 23, 2006:D1. [reprinted on Post-Gazette.com]
BOOK/REPORT
Preventing Medication Errors: Quality Chasm Series. Classic icon
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
Medication Reconciliation Handbook.
Oakbrook Terrace, IL: Joint Commission Resources and the American Society of Health-System Pharmacists; 2006. ISBN: 0866889566.
 
Last Updated: October 2012