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This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;Epub May 22.
Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.
Stuijt CCM, van den Bemt BJF, Boerlage VE, et al. BMC Health Serv Res. 2022;22:722.
Medication reconciliation can reduce medication errors, but implementation practices can vary across institutions. In this study, researchers compared data for patients from six hospitals and different clinical departments and found that hospitals differed in the number and type of medication reconciliation interventions performed. Qualitative analysis suggests that patient mix, types of healthcare professionals involved, and when and where the medication reconciliation interviews took place, influence the number of interventions performed.
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. Res Soc Admin Pharm. 2022;18:2651-2658.
Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.
Zhu J, Weingart SN. UpToDate. Mar 18, 2022.
Unsafe medication systems in hospitals can lead to adverse drug events (ADEs). This review discusses patient care and organizational factors that contribute to ADEs, methods to detect medication errors, and prevention strategies such as medication reconciliation and enhanced pharmacist participation.
Andersen TS, Gemmer MN, Sejberg HRC, et al. Pharmaceuticals (Basel). 2022;15:142.
Conducting a complete medication reconciliation in the emergency department may be difficult or even impossible if the patient is unable to speak for themselves. In these instances, clinicians must rely solely on electronic records of medication prescriptions, which do not always reflect the medications being taken. This analysis of prescriptions entered into the Danish Shared Medication Record (SMR) and patient reports of medications taken showed 81% of patients had at least one discrepancy, the most common of which was discontinued medications still showing in the SMR.
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.
van der Nat DJ, Taks M, Huiskes VJB, et al. Int J Clin Pharm. 2022;44:539-547.
Medication reconciliation is a common tool used to identify medication discrepancies and inconsistencies. This study explored clinically relevant deviations in a patient’s medication list by comparing the personal heath record (used by patients) and medication reconciliation during hospital admission. Clinically relevant deviations were higher among patients with individual multi-dose packaging and patients using eight or more medications.
Dionisi S, Di Simone E, Liquori G, et al. Public Health Nurs. 2022;39:876-897.
Causes of medication errors occurring in home care may differ from those in the hospital setting. This systematic review identified three main risk factors for medication errors in the home: transition documentation, medication reconciliation, and communication among the multidisciplinary team. Most studies recommend involvement of a pharmacist as a member of the care team.
Mekonnen AB, Redley B, Courten B, et al. Br J Clin Pharmacol. 2021;87:4150-4172.
Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11:CD009985.
Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.
Davila H, Rosen AK, Stolzmann K, et al. J Am Coll Clin Pharm. 2022;5:15-25.
Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43:1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21:1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.
Chauhan A, Walpola RL. Int J Qual Health Care. 2021;33:mzab145.
Health care decision making and delivery are vulnerable to unconscious bias. This commentary discusses strategies in place to address unconscious bias as it affects medication safety. The authors suggest a focus on engaging ethnic minority consumers as partners to design improvement programs to enhance medication delivery.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11:e054364.
Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.
Morse KE, Chadwick WA, Paul W, et al. Pediatr Qual Saf. 2021;6:e436.
The goal of medication reconciliation is to identify medication inconsistencies at hospital discharge. This study identified six common medication reconciliation errors at discharge – duplication, missing route, missing dose, missing frequency, unlisted medication, and “see instructions” errors. The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication and “see instructions” errors were most common. 
Breuker C, Macioce V, Mura T, et al. J Patient Saf. 2021;17:e645-e652.
In this prospective observational study, hospital pharmacy staff obtained the best possible medication history for adult patients at admission to and discharge from one French hospital. Unintended medication discrepancies were identified in nearly 30% of patients. Most medication errors were omissions and risk of error increased with the number of medications.