Medication Reconciliation Flowchart

1. Running head: MEDICATION RECONCILIATION FLOWCHART 1
Medication Reconciliation Flowchart
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2. MEDICATION RECONCILIATION FLOWCHART 2
Medication Reconciliation Flowchart
Description of the Patient Safety Problem
Medication reconciliation is the process in which nurses, physicians, and other healthcare
professionals work with the patients to ensure that medical information is accurate and complete
at the various interfaces of care. Medical reconciliation is necessary in mitigating adverse drug
effects, which are a leading cause of morbidity and mortality within health care systems around
the globe(Andel, Davidow, Hollander, & Moreno, 2012). Many adverse drugs events occur due
to poor communication between medical professionals and between medical professionals and
patients especially in cases where care is transferred. Care transfer refers to instances when
patients are admitted to a care facility, moved between wards within a hospital or are discharged
home or to a residential facility.
Over fifty percent of medical errors that occur in the clinical environment is estimated to
occur on admission or discharge. Further, thirty percent of these errors can harm patients. Errors
occurring on admission entail obtaining the patient’s medical history, when prescribing
medicines, and when recording the medications in the medical records. According to the World
Health Organization (2015), 67 percent of patient’s prescription histories recorded on admission
are inaccurate. Additionally, up to 80 percent of patients have discrepancies between the
prescribed medications and the medications they are taking at home(Elias, Damle, Casale,
Branson, Churi, Komatireddy & Feramisco, 2015). The repercussions of inadequate transition
from a hospital to home are far-fetching for patients (World Health Organization, 2014). They
include adverse drug effects, hospital readmission, and mortality.
Medication Reconciliation at Admission

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Flow Chart
Write the initial admission medication orders.
Obtain a Best Possible Medical History (BPMH)
Compare the orders with the BPMH.
Are there any
discrepancies?
Implement initial
admission medication
orders
Are they
intentional?
YES
Reconcile all the
discrepancies.
NO
Review all
admission
medication
orders
NO
Note the intention in
the health record
Y
E
S
Create a medication
administration record
(MAR)
Update the MAR and the
BPMH on the patient’s
medical record. END
START

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Description of the Process
Medication reconciliation starts with obtaining the patient’s best possible medication
history (BPMH). This means that the health care worker admitting the patient should compile a
comprehensive list of medications that the patient has previously taken or is currently taking.
They achieve this by interviewing the patients or their guardians, deriving information from
referral letters as well accessing previous medical information from electronic health records.
The Best Possible Medical History (BPMH) should include all drugs that the patient is taking,
both prescribed and non-prescribed. Prescribed medications are those taken under the advice of a
prescriber while the latter are not based on a prescribed advice. Complementary (herbal),
recreational drugs, and prn medication should be included in the Best Possible Medical History
(Elias, Damle, Casale, Branson, Churi, Komatireddy & Feramisco, 2015). Only if a patient or
their guardian are not in a positionto describe their medical history before admission should the
other sources be utilized to obtain their medication history or to clarify a conflicting piece of
information about them (World Health Organization, 2014). It is not professional for a heath care
professional to use other sources of information in the place of a thorough interview with a
patient or their guardians.
Next, the patient’s Best Possible Medical History is verified and documented. The
information should be verified with more than one source including their medication lists, the
federal medication database, inspecting their medication containers, or verifying with their home
care providers and community pharmacists. The Best Possible Medical History is a record of a
patient’s medication information including their generic and brand names, dosage, a patient’s
route and frequency of administration (McGonigle & Mastrian, 2012). A BPMH is different
from and more comprehensive than the conventional primary medication history. As such, it

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should be documented in a computer template that prompts for the required information(Elias,
Damle, Casale, Branson, Churi, Komatireddy & Feramisco, 2015).
The third step of the medical reconciliation process entails reconciling the Best Possible
Medical History with the prescribed medicines. Medication reconciliation on admission is in
figure 1 above. It is a retroactive modelwhereby medication admission orders are written before
the Best Possible Medical History has been obtained. The BPMH and the admission orders are
reconciled, whereby discrepancies are identified and resolved (World Health Organization,
2014).
To begin the reconciliation, patient’s conventional primary medication history is taken
and admission medication orders documented before the Best Possible Medical History is
created. When created, the Best Possible Medical History is compared retroactively against the
admission medication orders. Discrepancies are then identified and resolved as appropriate. The
discrepancies are categorized into intentional discrepancies and undocumented intentional
discrepancies. Undocumented intentional discrepancies are those which the prescriber makes an
intentional decision add, adjust, or stop a medication, but do not document the decision (Giles,
Harris, & Parker, 2010).Unintentional discrepancies are those which a prescriber changes, omits,
adjusts, or stops a medication that the patient was taking before they are admitted. The
reconciliation should occur within 24 hours of admitting the patient.
The final step entails communicating to the patient the Best Possible Medication
Discharge Plan at the end of the patient’s episode of care. The plan should also be communicated
to their personal care physicians, community pharmacy and the facility that will provide them
care next (Andel, Davidow, Hollander, & Moreno, 2012). On receiving the plan, all the

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recipients should make sure that they update their records so that they reflect an accurate record
of the patient’s current medications.
In any clinical process, patients are the only constants. Medication reconciliation,
therefore, will only work with the active involvement of patients and their families in the
process. Patients are best placed to provide accurate information about their medications(Huser,
Rasmussen, Oberg & Starren, 2011). As such, they should be educated about the essence of
participating in the medication reconciliation process. They should be encouraged always to
speak up if the think that there is a discrepancy or an error with their medication. They should
also be advised to keep an updated list of all the medications that they are currently taking.
Additionally, they should be advised to always bring their medications and medication records
with them when they come to the hospital. Achieving this would require the use of educational
tools and materials to support patients in self-maintaining their medication records.
Areas of Improvement
Patient and Family Involvement
After the Best Possible Medical History has been obtained, patients should continue to be
engaged in the subsequent steps leading to a successful medication reconciliation process. It is
important to notify them of any changes made to their medication records and regimen so that
they can have an understanding of how to continue taking their medicines. When they are
discharged to home and in ambulatory visits where the patient’s medication has been modified, it
is important that they receive counseling on the updated regimen (Howlett & Atkinson, 2012).
Conclusion
The process of medication reconciliation is complex because it encompasses a multitude
of professional disciplines across a broad spectrum of care (Huser, Rasmussen, Oberg & Starren,

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2011). While the fundamental guiding principle of communication alongside its value to the
safety of patients is widely accepted, the medication reconciliation process is sometimes
considered as exasperating. As such, the process may be resisted within a care setting if not
implemented in a systematic manner. It is recommended that a quality improvement approach is
applied in applying medical reconciliation.Medication reconciliation is a matter dealing with
information management and the implementation of medical reconciliation systems depends
largely on the existing staff in a health care organization as well as the systems and processes
established to collect, use, and communicate medication information. It is imperative that
information management activities that facilitate medication reconciliation are integrated into a
health care organization’s existing systems and processes as much as possible. To provide patients
with the safest form of care,it is important that licensed practical nurses and registered nurses follow the
steps outlined in the workflow for proper medication reconciliation. This will reduce the rate of infections
as well as the possibility of adverse effects occurring in a healthcare facility. Chances to improve the
efficiency of the medication reconciliation process need to be identified, prioritized and implemented.

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