Medication Reconciliation Process

Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It is also define as the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care.

Medication reconciliation is usually undertaken by a pharmacist and may include consulting several sources such as the patient, their relatives or caregivers, or their primary care physician. It requires an inter-professional team approach.

Medication reconciliation

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The pharmacist’s role is to coordinate the medication reconciliation process. The pharmacist, wherever possible, take primary responsibility for ensuring proper communication of medication information to patients/clients, families and other healthcare providers on admission, transfer, and discharge. The pharmacist ensures that medications are selected and ordered appropriately based on the patient’s clinical condition and other factors.

Guiding Principles Of Medication Reconciliation

1. An up-to-date and accurate patient medication list is essential to ensure safe prescribing in any setting.

2. A formal structured process for reconciling medications should be in place across all interfaces of care.

3. Medication reconciliation on admission is the foundation for reconciliation throughout the episode of care.

4. Medication reconciliation is integrated into existing processes for medication management and patient flow.

5. The process of medication reconciliation is one of shared accountability with staff aware of their roles and responsibility.

6. Patients and families are involved in medication reconciliation.

7. Staff responsible for reconciling medicines are trained to take the best possible medication history (BPMH) and reconcile medicines.

Process Of Medication Reconciliation

This process comprises five steps:

1) develop a list of current medications;

2) develop a list of medications to be prescribed;

3) compare the medications on the two lists;

4) make clinical decisions based on the comparison; and

5) communicate the new list to appropriate caregivers and to the patient.

The whole process can be shorten to three steps namely;

1. verify by collecting the list of medications, vitamins, nutritional supplements, over-the-counter drugs, and vaccines (collecting an accurate medication history);

2. clarify that the medications and dosages are appropriate; and

3. reconciliation (documenting every single change and making sure it “squares” with all the other medication information). 

For a newly hospitalized patient, the steps include obtaining and verifying the patient’s medication history, documenting the patient’s medication history, writing orders for the hospital medication regimen, and creating a medication administration record. At discharge, the steps include determining the postdischarge medication regimen, developing discharge instructions for the patient for home medications, educating the patient, and transmitting the medication list to the followup physician. For patients in ambulatory settings, the main steps include documenting a complete list of the current medications and then updating the list whenever medications are added or changed.

Admission medication reconciliation processes generally fit into two models: the proactive process or the retroactive process, or a combination of the two. The proactive model occurs when the best possible medication history (BPMH) is created prior to writing admission medication orders. In the retroactive model, admission orders are written before the BPMH is created. In both models, reconciliation takes place between the BPMH and the admission orders, discrepancies are identified and resolved.

Types of Medication Errors

Types of medication errors that can be prevented by reconciling medications may include:

1. failure to prescribe clinically important home medications while in hospital

2. incorrect doses or dosage forms

3. duplicating medication orders either because the patient may already be taking the drug or due to confusion between brand and generic versions of a drug or formulary substitutions

4. failure to clearly specify which home medications should be resumed and/or discontinued at home after hospital discharge

5. duplicate therapy at discharge (result of brand/generic name combinations or hospital formulary substitutions

6. as well as prescribing incorrect dosages.

Goal of Medication Reconciliation

The ultimate goal of medication reconciliation is to prevent adverse drug events (ADEs) at all interfaces of care (admission, transfer and discharge), for all patients.

Aim Of Medication Reconciliation

The aim is to eliminate undocumented intentional discrepancies and unintentional discrepancies by reconciling all medications, at all interfaces of care.

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An unintentional discrepancy occurs when the prescriber (usually the physician) unintentionally changes, adds or omits a medication the patient was taking prior to admission. But in undocumented unintentional discrepancy, the alterations is not documented.

Importance Of Medication Reconciliation

The average hospitalized patient is subject to at least one medication error per day. More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients. Of these errors, about 20 percent are believed to result in harm. 

Chronic medications are stopped in about 11% of the patients after elective surgeries and 33% of the patients after admission to intensive care unit. The most common omissions are inhalers and analgesia. There are also a small minority of errors in prescribing drugs such as insulin or warfarin, which could have catastrophic consequences including death of the patient. Many of these errors would be averted if medication reconciliation processes were in place. Pharmacist involvement help reasons for drug discontinuation being documented and adverse drug reactions being reconciled in the prescription charts. The following are reason for medication reconciliation;

1. It helps avoid medical errors that could result from an incomplete understanding of past and present medical treatment.

2. There is less chance that a medication or prescription is forgotten or overlooked.

3. Health care provider can more effectively work with you to consolidate and avoid unnecessary duplications of medications or prescriptions that treat the same symptoms.

4. Health care provider can look for dosing errors and discuss proper administration of your medications.

5. With a complete inventory of your medications, your provider can help you identify and avoid adverse drug interactions.

Adoption Of Medication Reconciliation Process

The process of gathering, organizing, and communicating medication information across the continuum of care is not straightforward.

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1. tremendous variation in the process for gathering a patient’s medication history.

2. there are at least three disciplines generally involved in the process—medicine, pharmacy, and nursing—with little agreement on each profession’s role and responsibility for the reconciliation process.

3. there is often duplication of data gathering with both nurses and physicians taking medication histories, documenting them in different places in the chart, and rarely comparing and resolving any discrepancies between the two histories.

4. patient acuity may influence the process of reconciliation. For example, a patient admitted for trauma may result in cursory data gathering about the medication history. Alternatively, a patient with numerous comorbidities may stimulate gathering a more complete list of current medications.

5. Patient knowledge of health and drugs may affect medication reconciliation process.