This document discusses medication reconciliation, which is a process used to reduce adverse medication events during transitions of care. It involves creating an accurate list of all medications a patient takes and comparing it to physician orders. Common errors like omissions and duplications can be prevented. The best possible medication history is collected from multiple sources like patients and providers. Medications are then reconciled by reviewing, continuing, changing, withholding or stopping drugs based on the care plan. Providing accurate information at transfers and discharge leads to safer ongoing care by reducing errors and confusion. Widespread use of medication reconciliation is recommended.

1. M E D I C A T I O N R E C O N C I L I A T I O N ( A
S Y S T E M A T I C P R O C E S S T O R E D U C E A D V E R S E
M E D I C A T I O N E V E N T S )
Kenneth B. DAVID
KASU/12/PHM/1005
PCP504 Presentation

2. Introduction
 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
physician's admission, transfer, and/or discharge orders, with the goal of
providing correct medications to the patient at all transition points within
the hospital.

3.  A process to reduce adverse medication events by:
 Ensuring patients receive all intended medicines
 Mitigating common errors of transcription, omission, commission and duplication
 Ensuring accurate, current and comprehensive medication information follows patients on
transfer and discharge

4. What’s the Problem?

5. Examples - Medication Errors
Aspirin and clopidogrel
ceased in ICU and not
recommenced when
patient transferred to ward
Patient suffered
sudden cardiac arrest
resulting in death
May have
contributed to
patient’s death
Patient prescribed ramipril
1.25mg daily, medication
chart was rewritten as
ramipril 12.5mg daily
Patient suffered pre-
syncopal episode, was
transferred to HDU and
required noradrenaline
Caused
temporary harm
and required
intervention
Patient initiated on new
cardiac medication,
discharged with no
summary or medicine
Patient became acutely
unwell and was re-
admitted
Caused
temporary harm
and required
intervention

6.  *A medication error is not an adverse event until it causes harm to the
patient
 ∗Medication errors are common and often occur when patients move
between healthcare settings
 ∗Medication errors can be decreased when a client has and uses a list
 ∗Reconciliation time can be reduced at all settings when the patient has an
updated list

7. What is a Best Possible Medication History (BPMH)?
 The term BPMH is used as it acknowledges that it is not always possible to
obtain or ascertain whether the medication history taken is accurate and
complete but it identifies that a concerted effort has been made to ensure it
is as complete and accurate as possible, given the resources available. This is
done by using a combination of sources to obtain and verify the information
gathered.

8. STEPS INVOLVED IN MEDICATION
RECONCILIATION
 A. Collecta BPMH
 Gather an accurate as possible medication history, using a combination of
sources of medicines information:
 Patient/care giver’s interview when possible
 AND/OR
 Other sources of medicines information e.g. community healthcare provider

9. b. Confirm the Accuracy of the History
 Verify the obtained information
 Use a secondary source to confirm the interview information OR
 Use two or more sources of information to obtain and verify the medication history
 Explore inconsistencies between the different sources
 The collecting and confirming steps may occur in succession or concurrently

10. c. Compare the history with prescribed medicines
 Use the BPMH when determining the medications to be prescribed on
admission:
 Decide and document the plan for each medicine e.g. to continue,
change, withhold or cease
 Check the medicines that have been prescribed follow the plan
 Compare pre-admission and current medications at every transfer of
care

11. d. Supply AccurateMedicines Information
 Between wards, hospitals and at discharge consider:
 Are all medicines prescribed still relevant?
 Do any pre-admission medicines withheld/changed need to be
recommenced/changed back?
 Are the changes, including reasons clearly documented?
 Is the list complete and clear for your patient, your team and
the next care provider?


12. RECOMMENDATION
 Increase pharmacy’s role in medication
reconciliation during transitions of care.
 Implement an interdisciplinary approach to
medication reconciliation—which includes hospital,
nursing home, and pharmacy—that occurs before or
during the care transition
 Implement interventions to assure indications and
diagnoses are documented for all prescribed
medications

13. Summary/ Conclusion
The risks and costs of poor medication reconciliation as patient transitions from home to a hospital are significant in
terms of patient safety, and efficiency and cost to the health care system.
•A BPMH results in safer prescribing
•Documenting a BPMH and plan
•Improves communication between the health care team
•Reduces error, confusion and re-work
•Reduces time and error at discharge
•Reconciling at admission, ward/hospital transfer and discharge reduces medication errors and patient harm
•Providing accurate information at transfer/discharge results in safe ongoing care

15. REFERENCES
 Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN,
Etchells EE. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med 2005;165:424-9.
 Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication
reconciliation in the acute care setting: opportunity and challenge for
nursing. J Nurs Care Qual 2005;20:95-8.
 Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting
medication errors at hospital admission and discharge. Qual Saf Health
Care 2006;15:122-6.