Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the admission, transfer, and/or discharge orders. The goal is to ensure that all correct medications are to the patient and to prevent unintended changes or omissions of medications at all transition points.
Experience from hundreds of organizations has shown that poor communication of medical information at transition points is responsible for as many as 50 percent of all medication errors and up to 20 percent of adverse drug events in the hospital [Preventing Medication Errors
(Institute of Medicine, 2006)]. Each time a patient moves from one setting to another where orders change or must be renewed, clinicians should review previous medication orders alongside new orders and plans for care, and reconcile any differences. If this process does not occur in a standardized manner that is designed to ensure complete reconciliation, medication errors may lead to adverse events and harm.
Changes for Improvement
Reconcile Admission Orders with Home Medication Lists
When a patient is admitted to the hospital, the list of all medications ordered upon admission to the hospital must be compared — or reconciled — with the list of medications the patient was taking before entering the hospital. If any pre-admission medication is not either ordered or explicitly declared to be inappropriate, the nurse or pharmacist should contact the patient’s physician. The physician should then either order the medication or formally confirm that the omission was deliberate. Prescribers should routinely document the reason for excluding any medication on admission.
Reconcile Medication Orders When Patients are Transferred to Other Care Units
When a patient is transferred from one patient care unit to another, a prescriber may write new medication orders. Before the actual transfer, a nurse or a pharmacist should look at the medication administration record and compare the medications the patient was taking prior to admission and those that have been ordered in the sending unit against the medications in the transfer orders. Because some medications are not appropriate in every setting, comparing the two groups of medications is particularly important if the patient is moving from one level of care to another. (For example, some hospitals have policies that restrict the use of intravenous Dopamine to Intensive Care Units.) If any pre-transfer medication is not ordered again or explicitly declared to be inappropriate, a nurse or pharmacist should contact the patient’s physician. The physician should then either order the medication or formally confirm that the omission is deliberate.
Reconcile Discharge Instructions and Prescriptions with the Medication Administration Record
After discharge from the hospital, a patient may continue taking some medications at home, but not perhaps all of them. Therefore, it is extremely important to compare the discharge medication instructions and prescriptions with the medication list collected on admission and the medication administration record (MAR) to check for any discrepancies. If a medication the patient has been receiving in the hospital is not in the discharge instructions, and there is no adequate documentation indicating why that medication has been omitted, then a nurse or pharmacist should contact the patient’s physician to verify whether or not the patient should discontinue use of the medication
Reconciliation in Outpatient Settings