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Medication Reconciliation Victory After an Avoidable Error

Timothy W. Cutler, PharmD | March 21, 2009
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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 problem.(5) 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 transition.

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 nurse.(10) 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 settings.

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 history).

Timothy W. Cutler, PharmD

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 PubMed]

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 PubMed]

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 PubMed]

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 PubMed]

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 PubMed]

11. Glintborg B, Poulsen HE, Dalhoff KP. The use of nationwide on-line prescription records improves the drug history in hospitalized patients. Br J Clin Pharmacol. 2008;65:265-269. [go to PubMed]


Table. Selected Potentially Inappropriate Medications to Avoid in Older Adults: Independent of Diagnosis or Conditions.

Generic Drug Name Concerns


High risk of developing central nervous system adverse events.

Cyclobenzaprine, methocarbamol, carisoprodol, other muscle relaxants

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

Amitriptyline, doxepin

High risk of anticholinergic adverse events, sedation, and weakness.

Diazepam, flurazepam, chlordiazepoxide, other long-acting benzodiazepines

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 used.

Dicyclomine, hyoscyamine, other gastrointestinal antispasmodic drugs

High risk of anticholinergic adverse events, questionable efficacy.

Diphenhydramine, chlorpheniramine, hydroxyzine, other anticholinergic antihistamines

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

Phenobarbital, 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 adults.

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

Mineral oil

Potential for aspiration, safer alternatives available.

Desiccated thyroid

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.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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