Cases & Commentaries

Medication Reconciliation Victory After an Avoidable Error

Commentary By Timothy W. Cutler, PharmD

The Case

A 91-year-old woman, previously active and
independent, recently developed weight loss, confusion, and falls
without injury. She lived alone. Late one night, her family visited
and found her on the floor of her home. She was lethargic and
incontinent, and her speech was slurred. She did not appear to
recognize her family members. She was taken to the hospital and
admitted for altered mental status and dehydration. Upon arrival to
the ward, the admitting nurse attempted to reconcile her home
medications with those ordered on admission. However, the patient
was unable to tell the nurse which medications she was taking. A
family member was asked to return to the patient's home, gather all
of her medications, and bring them to the hospital so that
medication reconciliation could be performed. In all, seven
prescription medications were returned, including Flexeril 10 mg
TID, glipizide 10 mg daily, Neurontin 200 mg TID, lisinopril 10 mg
daily, gabapentin 200 mg TID, cyclobenzaprine 10 mg TID, and Lortab
5 mg as needed for pain. Some medications had been filled at a
local pharmacy, while others were filled by a mail-order pharmacy.
The admitting physician recognized that several of the medications
were duplicates (Flexeril is the brand name of cyclobenzaprine;
Neurontin the brand name of gabapentin), and he adjusted the
medication regimen accordingly.

The day after admission, the patient was more
alert and responsive to questions. Her medications were reviewed,
and she reported that she was taking all of the medications, as
prescribed, from the bottles that were retrieved from her home.
Unaware that any of the medications were duplicates, she thought
she was taking exactly what her physician had intended.

The Commentary

The direct costs of drug-related morbidity and
mortality were estimated to exceed $177 billion in 2000, of which
70% ($121 billion) was attributed to hospital admissions.(1) The
Institute of Medicine reports that up to 1.5 million preventable
adverse drug events occur in the United States annually.(2)
Furthermore, potentially inappropriate medication (PIM) use is a
significant problem in community-dwelling elders, accounting for an
estimated $7.2 billion in health expenditures in 2001.(3) As
a result of continued medication misadventures in the United
States, the Joint Commission has established specific National
Patient Safety Goals (NPSG) to reduce the impact of medication
errors on patient safety.(4)
This case identifies two important aspects in the safe and
effective use of medications in the elderly. First, the continued
use of PIM in older adults remains a problem and dramatically
increases the likelihood of developing a drug-related
Second, medication reconciliation can identify potential and actual
drug-related problems when performed across the continuum of care
as outlined by the Joint Commission.(6)

Criteria for PIM in the elderly were first
developed by Mark Beers in 1997 and are commonly referred to as
"Beers criteria" or the "Beers list."(7) The Beers criteria were updated in 2003 using a
literature review and expert consensus.(8) The updated Beers list includes drugs to be avoided
regardless of disease state or condition and a list of drugs to be
avoided in patients with certain diagnoses or conditions. Muscle
relaxants like cyclobenzaprine are included on the Beers list of
PIM (see Table for a partial list of medications to be avoided
in older adults) regardless of condition. Although the case above
highlights the potential dangers of therapy duplication, it also
illustrates the importance of minimizing use of medications that
should be avoided in the elderly population. Studies indicate that
23%–40% of community-dwelling elderly patients use PIM, and
that 2.6% of elderly patients take medications that should
always be avoided.(3,9) A
study evaluating medication use in older adults identified a
threefold increase in the incidence of documented drug-related
problems when at least one PIM was used in older adults.(5)
Prescribers and other health care providers must work together to
minimize the use of PIM in older adults. It is possible that this
medication error could have been avoided if this patient was not
taking cyclobenzaprine in the first place.

The 2008 and 2009 NPSG from the Joint
Commission highlight medication reconciliation as a requirement for
hospitals. The Joint Commission recognizes that patients are most
at risk for medication errors when transitioning across different
levels or between different providers of care. The process of
medication reconciliation was established to reduce adverse
medication events that may occur as a result of this

In the case described above, the medication
reconciliation process identified the cause of the admission and
resulted in prompt treatment of the patient (in this case,
discontinuation of duplicate therapies) as opposed to reducing
future medication errors. Communication among health care providers
continues to be a focus of the NPSG and the Joint Commission. There
appears to have been a breakdown in communication among health care
providers and the patient in the case described above. In this
situation, the patient should have received counseling and
educational material from the pharmacies describing the medication,
including the brand and generic name, as well as drug information
from a pharmacist that included the purpose and side effects of the
prescribed treatment. Furthermore, the use of multiple prescribers
and multiple pharmacies could have contributed to the use of
duplicate therapies. Using a single pharmacy for medications or a
national electronic prescription registry also could have reduced
the chance of this error occurring.

Interestingly, the use of
technology—often cited as a primary process to help reduce
medication reconciliation errors—may not be sufficient
without further inquiry by a health care provider. A small study
determined that 57% of electronic medical record medication
histories did not match those obtained telephonically by a
Furthermore, obtaining medication information from the patient
alone may not be enough. Glintborg and colleagues found that
patients admitted to a hospital in Denmark failed to report 27% of
prescription medications filled in the last month when compared to
actual prescriptions identified in the national electronic
prescription file.(11)
The same study evaluated self-reported medication use during a home
visit and found that 18% of medications filled in the last month
were not reported. Although no studies or guidelines describe the
best approach to medication reconciliation, a process that uses
both electronically available medication records as well as data
from direct interviews of patients and/or families appears to be
the most logical and accurate approach.

With the increased use of electronic
prescribing and real-time data feeds/decision support from
third-party organizations, the medication reconciliation process
and identification of PIM in the elderly can be enhanced not only
upon hospital admission but also in ambulatory care and pharmacy
settings. In the case above, it is unclear if the duplicate
medications used by the patient were current and recently filled by
the patient. If so, a pharmacist or physician with access to the
complete medical record and prescription fill history could have
identified the duplicate therapy and possibly prevented this
hospital admission. Furthermore, a clinician recognizing the
importance of avoiding PIM in the elderly might have prevented or
mitigated the impact of this error. The focus of medication
reconciliation in the hospital has reduced medication errors;
however, more emphasis should be placed on accurate medication
histories and appropriate prescribing practices in ambulatory care

Take-Home Points

  • All health care providers should be
    aware of medications that are best avoided in general or in
    specific populations such as the elderly. The Beers list is a
    useful resource.
  • More emphasis should be placed on the
    implementation of medication reconciliation processes in ambulatory
    care settings.
  • When performing medication
    reconciliation, multiple sources of information should be used to
    obtain accurate and complete medication histories (e.g., electronic
    medical records, pharmacy records, and patient/family

Timothy W. Cutler,

Assistant Professor of Clinical Pharmacy

Director, UCD–Sacramento Experiential Program

University of California,
San Francisco, School of Pharmacy


1. Ernst FR, Grizzle AJ. Drug-related morbidity
and mortality: updating the cost-of-illness model. J Am Pharm Assoc
(Wash). 2001;41:192-199. [go to

2. Institute of Medicine. Report Brief.
Preventing Medication Error. Washington, DC: National Academies
Press; 2006. [Available at]

3. Fu AZ, Jiang JZ, Reeves JH, Finchman JE, Liu
GG, Perri M 3rd. Potentially inappropriate medication use and
healthcare expenditures in the US community-dwelling elderly. Med
Care. 2007;45:472-476. [go
to PubMed]

4. 2009 Hospitals' National Patient Safety Goals.
Joint Commission on Accreditation of Healthcare Organizations.
Oakbrook Terrace, IL: The Joint Commission; 2009. [Available at]

5. Fick DM, Mion LC, Beers MH, Waller JL. Health
outcomes associated with potentially inappropriate medication use
in older adults. Res Nurs Health. 2008;31:42-51. [go to

6. Joint Commission on Accreditation of
Healthcare Organizations, USA. Using medication reconciliation to
prevent medication errors. Sentinel Event Alert. July 26,
2006;35:1-4. [Available at]

7. Beers MH. Explicit criteria for determining
potentially inappropriate medication use by the elderly. An update.
Arch Intern Med. 1997;157:1531-1536. [go to PubMed]

8. Fick DM, Cooper JW, Wade WE, Waller JL,
Maclean JR, Beers MH. Updating the Beers Criteria for potentially
inappropriate medication use in older adults: results of a US
consensus penal of experts. Arch Intern Med. 2003;163:2716-2725.
[go to

9. Zhan C, Sangl J, Bierman AS, et al.
Potentially inappropriate medication use in the community-dwelling
elderly: findings from the 1996 Medical Expert Panel Survey. JAMA.
2001;286:2823-2829. [go to

10. Orrico KB. Sources and types of discrepancies
between electronic medical records and actual outpatient medication
use. J Manag Care Pharm. 2008;14:626-631. [go to

11. Glintborg B,
Poulsen HE, Dalhoff KP. The use of nationwide on-line prescription
records improves the drug history in hospitalized patients. Br J
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Table. Selected
Potentially Inappropriate Medications to Avoid in Older Adults:
Independent of Diagnosis or Conditions.

Generic Drug


High risk of developing central nervous system
adverse events.

methocarbamol, carisoprodol, other muscle relaxants

High risk of anticholinergic adverse events,
sedation, and weakness and generally poorly tolerated by the
elderly with questionable efficacy.


High risk of anticholinergic
adverse events, sedation, and weakness

flurazepam, chlordiazepoxide, other long-acting

Older adults have a higher sensitivity to
benzodiazepines, causing sedation, weakness, and increased risk of
falls especially when benzodiazepines with a long half-life are

hyoscyamine, other gastrointestinal antispasmodic drugs

High risk of anticholinergic adverse events,
questionable efficacy.

chlorpheniramine, hydroxyzine, other anticholinergic

High risk of anticholinergic adverse events,
confusion, sedation, risk of falls; nonanticholinergic
antihistamines preferred.

other barbiturates

Highly addictive, high risk of adverse events
including sedation, risk of falls.


Increased risk of confusion, accumulation,
neurotoxic active metabolite that may accumulate in older

Fluoxetine Long half-life
that may accumulate causing central nervous system stimulation,
sleep disturbances, and agitation.


Potential for aspiration, safer alternatives


Concerns about cardiac effects, safer
alternatives available.

Adapted with permission from American
Medication Association. Original table © 2003 American Medical
Association. In: Fick DM, Cooper JW, Wade WE, et al. Updating the
Beers Criteria for Potentially Inappropriate Medication Use in
Older Adults. Arch Intern Med. 2003;163:2716-2725.