Background

Patients admitted to a hospital commonly receive new medications or have changes made to their existing medications. As a result, the new medication regimen prescribed at the time of discharge may inadvertently omit needed medications that patients have been receiving for some time. Alternatively, new medications may unintentionally duplicate existing medications. For example, a physician might prescribe a calcium channel blocker to a patient who has hypertension but is already taking another medication from the same drug class.

Such unintended inconsistencies in medication regimens may occur at any point of transition in care (eg, transfer from an intensive care unit to a general ward), not just at hospital admission or discharge. Studies have shown that unintended changes in medications occur in 33% of patients 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.

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

While the importance of medication reconciliation is universally recognized, there is no consensus on the best method of carrying out the process of reconciling medications. A variety of methods have been studied, including having pharmacists perform the entire process, linking medication reconciliation to existing computerized provider order entry systems, and integrating medication reconciliation within the electronic medical record system. Another avenue being explored is involving patients in reconciling their own medications.

The evidence supporting patient benefits from reconciling medications is relatively scanty. Interventions led by pharmacists or utilizing information technology have reduced actual and potential medication errors, but as yet, no system has resulted in an improvement in clinical outcomes. The effect of electronic systems and nurse-led processes has yet to be determined.

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 requirement does not mandate specific mechanisms by which this process should take place.