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.
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.
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."