Patients often receive new medications or have changes made to their existing medications at times of transitions in care—upon hospital admission, transfer from one unit to another during hospitalization, or discharge from the hospital to home or another facility. Although most of these changes are intentional, unintended changes occur frequently for a variety of reasons. For example, hospital-based clinicians might not be able to easily access patients' complete pre-admission 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. These discrepancies place patients at risk for adverse drug events (ADEs), which have been shown to be one of the most common types of adverse events after 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
The evidence supporting patient benefits from reconciling medications is relatively scanty. Most medication reconciliation interventions have focused on attempting to prevent medication errors at hospital admission or discharge, but the most effective and generalizable strategies remain unclear. A 2012 systematic review of 26 inpatient medication reconciliation studies found some evidence that pharmacist-led processes could prevent medication discrepancies and potential ADEs after discharge, a finding corroborated by a 2013 systematic review published as part of the AHRQ Making Healthcare Safer II report. However, both these reviews noted that the actual clinical effect of medication discrepancies after discharge appears to be small, and therefore, medication reconciliation alone does not reduce readmissions or other adverse events after discharge.
Information technology solutions are being widely studied and also appear to prevent unintended medication discrepancies, but their effect on clinical outcomes is similarly unclear. This may be in part due to the fact that medication discrepancies can persist even in organizations with fully integrated electronic medical records. Several recent studies also investigated the role of enhanced patient engagement in medication reconciliation in the outpatient setting and after hospital discharge. These efforts are promising but also lack evidence regarding the impact on medication error rates.
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 medicationsâ€¦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."