Cases & Commentaries

Medication Reconciliation: Whose Job Is It?

Spotlight Case
Commentary By Eric G. Poon, MD, MPH

Case Objectives

  • Appreciate the prevalence and impact of
    medication discrepancies at times of transition in the health care
  • List barriers to successful medication
  • Understand best practices for
    reconciling medications.

Case & Commentary: Part 1

A woman with a history of seizures was
scheduled for repair of a prolapsed rectum. A consultation prior to
surgery listed her home medication as "Neurontin 250 mg." When
admitted for surgery, the patient reported to the anesthesiologist
that she took Zarontin (ethosuximide) 250 mg twice daily. This was
recorded on her preanesthesia care record where another entry for
Neurontin had been entered and crossed out. The admitting history
and physical note listed her current medications as "See her list."
Postoperatively, the patient was prescribed Neurontin (gabapentin)
250 mg twice daily.

Hospital admissions and discharges are complex
events, characterized by multiple handoffs among health care
providers and numerous changes to the patient's therapeutic plan.
The intended medication regimen before, during, and after the
hospital stay often becomes a point of confusion for patients and
clinicians during care transition points across the hospital and
outpatient settings. Much of this confusion is fueled by multiple
changes to medication regimens (1),
discontinuity of care (2),
short hospitalizations, and inadequate patient education.(3,4)
Recent research strongly suggests that such confusion is a major
cause of medication errors and adverse drug events
(ADEs).(5-9) A
recent systematic review on errors in medication history at
admission estimated that 54%–67% of all admitted patients
have at least one discrepancy between the medication history
obtained by the admitting clinicians and the actual preadmission
regimen and that, in 27%–59% of those cases, such
discrepancies have the potential to cause harm.(10-12) A study of hospitalization-related ADEs also found
that medication discrepancy was the most common drug-related
problem at the time of discharge and the cause of half of all
preventable ADEs 30 days after discharge.(13)

Discrepancies such as the one illustrated by this
case can be prevented through a process commonly known as
medication reconciliation. As defined by the Institute for
Healthcare Improvement (IHI), medication reconciliation is a
process of identifying the most accurate list of all medications a
patient is taking—including name, dosage, frequency, and
route—and using this list to provide correct medications for
patients anywhere within the health care system. For patients
admitted to a hospital, this process involves comparing the
patient's current list of medications against the physician's
admission, transfer, and/or discharge orders.(14)

Given the patient safety risk posed by medication
discrepancies during transitions of care, leading patient safety
organizations, such as IHI and the Massachusetts Coalition for the
Prevention of Medical Errors, have developed recommendations and
tools to help health care organizations build robust medication
reconciliation processes.(14,15)
The Joint Commission's recent mandate for all health care
organizations to "accurately and completely reconcile medications
across the continuum of care" has heightened interest in this
important patient safety issue and has spurred many hospitals to
design and implement reliable and efficient medication
reconciliation systems.(16)

Case & Commentary: Part 2

When the order for gabapentin 250 mg twice
daily was received in the pharmacy, it was entered as "gabapentin
liquid" (gabapentin is not available in tablet/capsule strengths
that would allow a 250-mg dose). The pharmacist dispensed
gabapentin liquid 250 mg/5 mL with a note in the pharmacy computer
record to indicate "dispense size = 120 mL." This comment was
necessary so that the pharmacy would know how much was dispensed.
This comment also appeared on the prescription label and in the
electronic medication administration record (EMAR). The hospital
had recently implemented a new EMAR system, and there was no way to
suppress this information from appearing on the EMAR. The nurse
caring for the patient misinterpreted the EMAR and gave an
excessive amount of the gabapentin liquid on two consecutive
evenings (the exact amount was not documented). The patient told
the nurse that the amount of medicine given seemed to be more than
she was accustomed to taking. Shortly thereafter, the patient
became lethargic and could not walk. The pharmacist determined that
the gabapentin liquid had been refilled earlier than expected and
that an overdose had occurred. Although the overdosage was noted at
the time, the administration of the incorrect drug (Neurontin,
instead of Zarontin) was not recognized until several weeks later
when the event was investigated in more detail.

While the goals of medication reconciliation are
simple, efforts by hospitals nationwide to address this issue have
uncovered daunting challenges.(17)
Health care providers are often asked to piece together an accurate
medication history using information from multiple and often
imperfect sources, including the patient, his/her caregiver, the
primary care physician, medical specialists, outpatient medical
records, hospital discharge summaries, and community pharmacies. In
addition, each of the major disciplines involved, including
physicians, nurses, and pharmacists, often have divergent
expectations about who is responsible for reconciling medications
at various phases of the patient's care and how that should be
done. This uncoordinated set of reconciliation activities often
leads to either unnecessary redundancy or failure to share key
clinical information.

These challenges are well illustrated in this
case. First, the preoperative consultant sowed the seeds of this
adverse event by obtaining the wrong preadmission medication list
(PAML) from the patient. The consultant also failed to verify the
medication history; he did not contact the patient's PCP,
neurologist, or pharmacist, nor did he attempt to access the
patient's outpatient medical record or pharmacy dispensing record.
Second, although the medication history was later corrected by the
anesthesiologist, the clinician responsible for writing the
patient's inpatient medication orders was not alerted about the
correction, thus allowing the preoperative consultant's error to
propagate from the outpatient to the inpatient setting. Third, the
admitting physician and nurse failed to review the anesthesiology
records or reconfirm the patient's PAML with the patient, allowing
them to miss additional opportunities to correct the error. Fourth,
it is likely that the amended medication list generated by the
anesthesiologist was not available to the pharmacist, making it
impossible for the pharmacist to compare the admission orders
against the patient's PAML. Fifth, both the ordering physician and
the dispensing pharmacist blindly trusted the information passed on
to them from another clinical colleague, failed to question the
unusual dose of Neurontin, and, as a result, missed at least two
other opportunities to avert the adverse event.

How might adverse events like the one seen in
this case be prevented? While other strategies, such as the use of
unit dosing, barcode scanning during medication administration, and
better naming conventions to prevent mix-ups between "sound-alike"
pharmaceuticals, hold significant promise, the multitude of errors
involved in the medication reconciliation process points to the
need to re-engineer the process itself. As the best practices for
reconciling medications are being defined on the front lines,
several common themes have emerged from learning collaboratives
(14,15,17) and published literature (7,18,19):

  • Given the number of disciplines involved in the
    medication-use process, a robust medication reconciliation process
    should include participation by physicians, nurses, and
  • The process for medication reconciliation must
    be clearly defined by a multidisciplinary team, and
    responsibilities for each component of the process must be assigned
    to the parties involved. For example, the Figure illustrates a sample medication reconciliation
    process for surgical patients who are seen by nurse practitioners
    in the preoperative evaluation center before the surgery and are
    subsequently admitted into the hospital.(20) Once defined, the process needs to be validated with
    other front-line clinicians.
  • Implementers of the medication reconciliation
    process need to recognize that no single universal process will
    meet the needs of all patients entering a hospital, and that a
    limited number of different processes will need to be developed,
    depending on the patient population and patients' point of entry
    into the hospital.
  • Implementers should understand that successful
    implementation of the process will require significant training,
    education, and support from clinical leaders. Willingness to engage
    in continuous improvement and monitoring for compliance are likely
    success factors for a multidisciplinary team.
  • Implementers should expect to encounter
    resistance to the process by staff, because in many cases, staff
    will be asked to take on tasks that should have been done but were
    previously done incompletely (or not at all) due to the lack of
    time (e.g., asking the admitting physician to obtain an accurate
    medication history). Implementers should stand ready to articulate
    the safety benefits of the new process and to emphasize that
    understanding the patient's medication history is part of good
  • Patients should be leveraged as a resource in
    the medication reconciliation process, especially since they stand
    to gain the most from a safe medication-use process. Patients and
    families should be encouraged to keep an up-to-date list of
    medications. They should also understand why they take each of the
    medications as well as why medication changes occur. In turn, the
    medical staff should ensure that during the discharge process
    patients are appropriately educated about any changes in medication

Using the aforementioned principles, many
organizations have begun to experience success.(7,18,19) In addition, as hospitals nationwide tackle this
problem, novel approaches have emerged. One such approach involves
the use of information technology to facilitate the process of
medication reconciliation. Specifically, for health care systems
that have access to reliable sources of patients' medication
history in electronic format, an electronic tool could facilitate
the verification of the patient's medication history and
construction of the PAML. Moreover, once verified, the electronic
PAML could be shared across multiple disciplines and inform the
decision making of physicians, nurses, and pharmacists during the
admission and discharge processes. For hospitals that have
computerized physician order entry (CPOE) systems, the electronic
PAML can also be used to facilitate the ordering of inpatient
medications during admission and construction of the
posthospitalization medication list during discharge.(20)
Hospitals are exploring this approach to increase the reliability
and decrease the time burden of the medication reconciliation
process. However, this approach, while promising, has not been
fully evaluated to determine its effectiveness and
cost-effectiveness. Furthermore, as we have learned about the
limitations of information technology in other health care
contexts, we need to understand that no amount of technology can
obviate the need to design a reliable process or secure buy-in from
front-line clinicians.

Take-Home Points

  • Failure to reconcile medications during
    transitions of care accounts for many preventable adverse
  • To design a robust medication
    reconciliation process, first define steps involved and decide who
    should be responsible for each step.
  • A reliable medication reconciliation
    system requires a multidisciplinary approach, often with the
    participation of physicians, nurses, and pharmacists across the
    continuum of care.
  • A one-size-fits-all approach is unlikely
    to work, even within one hospital.
  • Information technology can facilitate
    medication reconciliation if it is devised to support a
    well-designed process.

Eric G. Poon, MD, MPH
Assistant Professor of Medicine, Harvard Medical School
Division of General Medicine and Primary Care, Brigham and Women's

Faculty Disclosure: Dr. Poon has
received research funding from the Agency for Healthcare Research
and Quality. The commentary does not include information regarding
investigational or off-label use of products or devices. All
conflicts of interest have been resolved in accordance with the
ACCME Updated Standards for commercial support.


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Figure. Sample cross-functional flow chart,
defining the responsibilities for medication reconciliation for
elective surgical patients.
Reprinted with permission from Elsevier. In: Poon EG, Blumefeld B,
Hamann C, et al. Design and implementation of an application and
associated services to support interdisciplinary medication
reconciliation efforts at an integrated healthcare delivery
network. J Am Med Inform Assoc. 2006;13:581-592.

Click to enlarge.