Cases & Commentaries

Reconciling Doses

Spotlight Case
Commentary By Frank Federico, RPh

Case Objectives

  • List the steps involved in medication
  • Describe the role of each of the
    stakeholders in medication reconciliation.
  • Discuss how medication reconciliation
    decreases the opportunity for medication errors and harm.

Case & Commentary: Part 1

A 68-year-old man with a history of diabetes
and atrial fibrillation maintained on warfarin presented to the
emergency department (ED) with fever and mental status change.
Lumbar puncture was attempted three times without success; empiric
treatment for meningitis was started. Further examination revealed
an area of cellulitis, and intravenous antibiotic therapy was
changed accordingly. At the time of admission, the patient was
unable to recite his medication history, and his wife was unclear
about the doses. However, the EMS run-sheet had a list of the
patient’s medications and doses. The patient was started on
the medication regimen per the EMS report.

Medication reconciliation is defined as
the process of collecting the best medication history possible,
verifying the list, and comparing it to orders written at
admission, transfer, and discharge. Although reconciliation is
always useful, it is particularly crucial when patients are unable
to provide a complete and accurate medication history or when the
history is not available to those who must make treatment

Evidence supporting the need for and the value of
medication reconciliation is strong. More than half of all
medication errors occur at the interfaces of care.(1) A review of 22 studies by Canadian researchers found
(in the absence of reconciliation) errors in up to 67% of
patients’ prescription medication histories.(2) Researchers at Johns Hopkins reported that an average
of ten prescriptions needed to be changed weekly in the ICU after
errors were identified through a reconciliation process.(3)

Implementation of a successful medication
reconciliation process ensures that each of the members of the
health care team has access to the list of medications that the
patient was taking prior to admission, what was ordered at
transitions of care, and a method to communicate an intentional
medication change or discontinuation. Rather than hoping that a
medication was appropriately discontinued and not overlooked, this
intervention provides a process to facilitate and standardize

The value of medication reconciliation has been
demonstrated “on the ground” by a number of
institutions, most prominently Luther Midelfort Hospital, a Mayo
Based on this work and the data cited earlier, medication
reconciliation has been one of the recommended changes for teams
participating in Institute for Healthcare Improvement (IHI)
collaboratives to reduce adverse drug events. Accordingly, when the
IHI launched its 100,000
Lives Campaign
(4) to
promote six changes proven to improve patient care and prevent
avoidable deaths, medication reconciliation was chosen as the focus
of efforts to reduce adverse drug events. Moreover, the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)
also selected medication reconciliation as one of its 2005 National
Patient Safety Goals.(5)

An important step in the process is to collect
the best medication list possible. Many patients can and do provide
accurate medication histories. When, as in this case, cognitive,
cultural, or other barriers prevent them from being able to provide
an accurate medication history, it is important to identify
effective ways to collect this history, accepting that the list may
initially be incomplete. Interviewing family members and contacting
primary care physician offices and local pharmacies may improve the
accuracy of the list. Some hospitals have worked with ambulance
staff to remind them to pick up prescription bottles or medication
lists that may be attached to refrigerators or medicine cabinets.
Each organization should have a process to continually improve the
system for collecting this medication history.

Case & Commentary: Part 2

After 2 days, the patient was transitioned to
Augmentin. While in hospital, the patient had been receiving 5 mg
of warfarin at bedtime, which, according to the EMS intake sheet,
was his usual outpatient dose. The team did not confirm this dose
with the patient’s family, primary physician, or pharmacy. At
the time of discharge, his INR was noted to be 4. Realizing the
warfarin dose was too high, the team instructed the patient to
decrease his dose to 3 mg at bedtime and to have his INR rechecked
in 3 days. After 3 days, his INR was 10. He was treated with
vitamin K. Two days later, the patient returned to the ED with back
pain, lower extremity weakness, and incontinence. He was found to
have an epidural hematoma, which was emergently evacuated. One week
post-operatively, the patient still had neurologic deficit.

Implementing a medication reconciliation process
may represent a change in work flow, requiring more time from staff
members. But organizations should be encouraged by those who have
successfully implemented a medication reconciliation process as
part of a larger medication safety program.(6)

To implement a successful medication
reconciliation process, organizations should first examine the
system presently in place.(7)
Using a high-level flow diagram may be helpful in determining the
different entry points into the hospital. An example can be found
here. A similar diagram for transfers and
discharges will help the team understand what is in place and how
to develop a system to support medication reconciliation at each

It is necessary to have a champion and a
multidisciplinary team to work on testing different changes that
will lead to the desired system. A useful instrument to record the
team members and their roles is available here. Senior leadership support is necessary to
align the process with other hospital initiatives, provide
resources for the project during its development, and remove

Due to the many entry points for admission into a
hospital, each hospital’s different levels of care, and each
hospital’s varied populations, there is no one way to
implement this process throughout the hospital. Accordingly,
organizations cannot expect to roll out a reconciliation process
overnight. Using a proven improvement methodology (eg, such as the
“Model for Improvement”) (8), hospitals can test and implement changes in different
settings, using the results of these experiences to inform

Medication reconciliation is a multidisciplinary
process. Selecting who should be involved in each step along the
way should be based on available resources and who can best
complete the task. For example, a physician, nurse, pharmacist, or
pharmacy technician can collect the medication history.(9)
Although pharmacists have been identified as being more effective
in taking such a history, there is no reason that they cannot train
others to do this well.(10) An
effective model may be one in which nurses collect a medication
history, pharmacists verify the information, and physicians use the
resulting list to aid in making decisions about drug therapy.
Physicians also complete the last step described: document reasons
or intentions to discontinue, change, or hold medications in a
manner that is clear to all.

Forms to collect medication histories have been
employed by many organizations. Some have adapted the forms to
serve as both a medication list and an order form. Adding columns
indicating whether a medication should be continued, discontinued,
or placed on hold minimizes re-writing and facilitates
communication among disciplines. This model may not be effective in
all organizations. As with any new process, hospitals must
determine if the changes introduce new opportunities for errors.
Forms have also been used in the transfer and discharge process.
Placing the list in a prominent place in the chart or using colored
paper facilitates access to this information. Several examples of
useful forms can be found on the Web sites of the Institute for Healthcare
and the Massachusetts Coalition for the Prevention of
Medical Errors

To complete the process of medication
reconciliation, at the time of discharge, the discharge
prescriptions must be reconciled with the most recent inpatient
orders and the patient medication list prepared at admission. This
comparison is useful to screen for therapeutic duplication,
possible drug interactions, omissions, or medications not ordered
during the inpatient stay.

Technology, if well designed and implemented, can
be a useful adjunct to medication reconciliation. Systems whose
electronic medical records allow medication histories to be
downloaded from an electronic nursing documentation system onto a
form reduce the time-consuming and error-prone process of manually
completing forms. At discharge, reformatting the patient medication
profile from the pharmacy system into a prescription form can
streamline the discharge prescription process.

Patients can play a significant role in helping
to design a process as well as being active participants in
medication reconciliation. Organizations such as McLeod Health in
South Carolina (11)
have engaged patients in developing a state-wide universal
medication form. Individually, patients should be encouraged to
carry their medication lists and present them at each health care
visit. An example of a patient medication card, which can
facilitate this process, can be found here.

Getting Started

Implementing a robust program of medication
reconciliation should not be viewed as necessary to meet the
regulatory or accreditation requirements but, rather, as a patient
safety initiative. The patient should be at the center of this
work. A successful medication reconciliation process is one in
which all stakeholders are accountable for its implementation,
spread, and sustainability. Here are some practical tips for
getting an effective program up and running:

  • Start with a small segment of the
    population. The process of collecting the medication history and
    writing orders for elective surgery patients will be different from
    that for patients admitted through the ED or a nursing home.
  • Evaluate the current system.
  • Identify who should participate in each
    step of the process and define the responsibility of each position.
    For example, nurses or pharmacists may be used to collect a
    medication history based on available resources.
  • Determine when reconciliation should be
    applied at transfer. Medication reconciliation applies if
    medications are reordered or there is intent to change
  • Select/create the forms. This is best
    done on paper, at first, even if the ultimate intent is to
    computerize the process.
  • Test changes in each area. Organizations
    must use a measurement strategy to determine the effectiveness of
    the process that has been implemented. For example, measuring the
    fraction of unreconciled medications at different transfer points
    can help those involved understand how well the process is

Take-Home Points

  • Medication reconciliation is an
    effective process to reduce errors and harm associated with the
    loss of medication information as patients transfer through
    different levels of care.
  • In order for medication reconciliation
    to be successful, all stakeholders must be involved.
  • Collect the best medication history
    possible, verify that history, and ensure that the information is
    available at the point of order writing.
  • Hospitals should develop different
    processes to support medication reconciliation based on patient
    entry points into the hospital and available resources.
  • Patients can play a vital role in
    medication reconciliation by carrying an up-to-date medication list
    and making it available to each provider they encounter.
  • Medication reconciliation should be
    applied any time medication orders are re-written or there is a
    change in treatment plan.
  • Reconciliation at discharge is necessary
    to avoid therapeutic duplication, drug interactions, and omissions
    of medications that may have been discontinued or placed on hold
    during hospitalization.
  • Many hospitals have successfully
    implemented reconciliation using low-technology solutions (eg,
    forms) rather than computers.

Federico, RPh
Director, Institute for Healthcare Improvement

Faculty Disclosure: Dr. Federico has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, his commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.


1. Rozich JD, Resar RK. Medication safety: one
organization’s approach to the challenge. JCOM.

2. Tam VC, Knowles SR, Cornish PL, Fine N,
Marchesano R, Etchells EE. Frequency, type and clinical importance
of medication history errors at admission to hospital: a systematic
review. CMAJ. 2005;173:510-515.
go to PubMed

3. Pronovost P, Weast B, Schwarz M, et al.
Medication reconciliation: a practical tool to reduce the risk of
medication errors. J Crit Care. 2003;18:201-205.
go to PubMed

4. 100K Lives Campaign. Institute for Healthcare
Improvement Web site. Available at:
Accessed October 10, 2005.

5. National Patient Safety Goals for 2006 and
2005. Joint Commission on Accreditation of Healthcare Organizations
Web site. Available at:
Accessed October 10, 2005.

6. Whittington J, Cohen H. OSF Healthcare’s
journey in patient safety. Qual Manag Health Care.
go to PubMed

7. Plsek PE. Quality improvement methods in
clinical medicine. Pediatrics. 1999;103 (suppl):203-214.
go to PubMed

8. Model for Improvement. Institute for
Healthcare Improvement Web site. Available at:
Accessed October 10, 2005.

9. Michels RD, Meisel SB. Program using pharmacy
technicians to obtain medication histories. Am J Health Syst Pharm.
go to PubMed

10. Nester TM, Hale LS. Effectiveness of a
pharmacist-acquired medication history in promoting patient safety.
Am J Health Syst Pharm. 2002;59:2221-2225.
go to PubMed

11. Medication Reconciliation can Save Your Life.
McLeod Health Web site. Available at:
Accessed October 10, 2005.