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March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.

Transitions of care from inpatient to outpatient settings are vulnerable to medication errors. This study found that patients receiving pharmacist-led medication reconciliation and education prior to discharge reported higher patient satisfaction scores; lower readmission rates compared to standard care patients were also observed. Pharmacists potentially prevented 143 medication safety events during medication reconciliation.
Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.
Montaleytang M, Correard F, Spiteri C, et al. Int J Clin Pharm. 2021;43:1183-1190.
Previous studies have found that discrepancies between patients’ medication lists and medications they are actually taking are common. This study found that sharing the results of medication reconciliation performed at admission and discharge with patients’ community care providers led to a decrease in medication discrepancies.
Volpi E, Giannelli A, Toccafondi G, et al. J Patient Saf. 2021;17:e143-e148.
Medication errors are a common and significant causes of patient harm. This retrospective study examined regional prescription registry (RPR) data at a single Italian hospital at 4 comparison points, pre-admission, admission, hospitalization, and post-discharge. Researchers identified 4,363 discrepancies among 14,573 prescriptions originating from 298 patients with a mean age of 71.2 years. Approximately one third of the discrepancies (1,310) were classified as unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition from  hospital discharge and the 9-month follow up. The study points to the need for enhanced communication between hospitalists and primary care providers at the hospital-home interface.
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Res Social Adm Pharm. 2020;17:677-684.
This study explored the impact of longitudinal medication reconciliation performed at transitions (admission, discharge, five-days post-discharge). Medication changes implemented due to longitudinal reconciliation prevented harm in 82% of patients. Potentially serious errors were frequently identified at hospital discharge and commonly involved antithrombotic medications.
Stolldorf DP, Mixon AS, Auerbach AD, et al. Am J Health Syst Pharm. 2020;77:1135-1143.
This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).
Alqenae FA, Steinke DT, Keers RN. Drug Saf. 2020;43:517-537.
This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.
Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  
Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.
Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.
Pellegrin K, Lozano A, Miyamura J, et al. BMJ Qual Saf. 2019;28:103-110.
Older adults frequently encounter medication-related harm, which may result in preventable hospitalizations. In six Hawaiian hospitals, hospital pharmacists identified older patients at risk of medication problems and assigned them to a community pharmacist who coordinated their medications across prescribers for 1 year after discharge. This post-hoc analysis of the intervention found that most medication-related harm occurred in the community (70%) rather than the hospital and that the intervention successfully reduced community-acquired harm.
Pevnick JM, Nguyen C, Jackevicius CA, et al. BMJ Qual Saf. 2018;27:512-520.
Among hospitalized patients, adverse drug events (ADEs) are a common and serious source of patient harm. Medication reconciliation at the time of hospital admission reduces preventable ADEs and is a National Patient Safety Goal. In this three-arm, nonblinded, randomized controlled trial, researchers compared pharmacist or pharmacy technician–performed medication reconciliation before admission orders were placed to usual care among patients with at least 10 medications. Pharmacist and technician reconciliation led to similarly large decreases in minor and life-threatening medication order errors. Although pharmacist-led reconciliation reduces in-hospital ADEs in research settings, real-world implementation has been more challenging. Previous WebM&M commentaries highlight the dangers of inadequate medication reconciliation in inpatient and outpatient settings.
Mekonnen AB, McLachlan AJ, Brien J-AE. J Clin Pharm Ther. 2016;41:128-144.
Medication reconciliation was initially established as a National Patient Safety Goal in 2005. This systematic review included 19 studies that supported the positive impact of pharmacy-led medication reconciliation on decreasing discrepancies during hospital admission and discharge.
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Am J Health Syst Pharm. 2015;72:1266-8.
Miscommunication during transitions of care can contribute to medication errors. This commentary describes an initiative to involve pharmacy students in care transitions services. Although the authors found that scheduling and training the students for the program was a challenge, 30-day readmission rates were lower for patients who received transitions of care services with pharmacy students versus those who did not.
Martin ES, Overstreet RL, Jackson-Khalil LR, et al. Am J Health Syst Pharm. 2013;70:18-21.
This commentary details the development of a medication reconciliation program to improve documentation at discharge, which included identifying high-risk drugs, forming a team of three full-time pharmacists, and tracking patients with pending discharges.
Schillig J, Kaatz S, Hudson M, et al. J Hosp Med. 2011;6:322-8.
Patients receiving warfarin therapy are at high risk for adverse events. Interventions to improve warfarin safety have focused on trigger tools, communication protocols, and the use of visual medication schedules. This study implemented a pharmacist-directed anticoagulation service to capture inpatients on warfarin and provide them with dosing, monitoring, and coordination of transition from the inpatient to outpatient setting. This cluster randomized trial demonstrated safer transitions in 73% more patients and a 32% reduction in the composite safety end point, which was driven by fewer patients experiencing an INR ≥ 5 (i.e., supratherapeutic levels that increase the risk of bleeding). This study adds further support to the role of pharmacists in driving medication safety, specifically for warfarin in both the inpatient and community settings. A past AHRQ WebM&M commentary discussed a case of a near miss due to a warfarin drug interaction that led to a supratherapeutic level following hospital discharge.
Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-95.
This study found that 62% of patients transferred between units during a hospitalization had at least one unintentional medication discrepancy. The most common discrepancy was medication omission, independent of which system was used (e.g., paper versus computerized).
Boockvar KS, Livote EE, Goldstein N, et al. Qual Saf Health Care. 2010;19:e16.
Addressing handoffs in patient care is a continued challenge, particularly around medication safety. Medication reconciliation was seen as a preventive strategy to handle such concerns, though the lack of proven strategies led The Joint Commission to soften its previous National Patient Safety Goal. A commonly held belief is that electronic health records (EHRs) provide solutions to communicating health information. This study compared medication reconciliation events for patient handoffs within a computerized VA system to a paper-based system outside the VA. Interestingly, there was no significant difference between medication discrepancies and adverse drug events (ADEs) in the highly computerized system. The authors suggest that their findings support a need for specialized tools to facilitate medication review at times of transfer. A past AHRQ WebM&M commentary discussed medication reconciliation after an avoidable error.