Overcoming the pitfalls of medication reconciliation

Any time there’s a hand-off in patient care, there’s an increased risk for a medication error. Medication reconciliation has been used to help bridge this hand-off communication on admission, between transfers in the hospital, and at discharge.

In the United States, medication errors harm an estimated 1.5 million people and kill several thousand each year, costing the nation at least $3.5 million annually.1 Medication reconciliation is a process that addresses the home medication list, but isn’t a complete medication history. 
Although many facilities have struggled to implement medication reconciliation, it can be achieved with an interdisciplinary approach that includes patient education. 
Medication reconciliation was the eighth National Patient Safety Goal to be implemented by The Joint Commission. The goal was designed to promote medication safety, and was originally announced by The Joint Commission in 2004 for survey in 2006.2,3 Any time there’s a hand-off in patient care, there’s an increased risk for a medication error. Medication reconciliation was designed to help bridge this hand-off communication on admission, between transfers in the hospital, and at discharge. Many hospitals struggled with implementation of and compliance with this goal. In 2009, The Joint Commission realized the difficulties that many organizations were experiencing and stopped surveying for compliance.3
In the September 2011 Comprehensive Accreditation Manual for Hospitals Update 2, medication reconciliation was changed to the third National Patient Safety Goal. The intent of the goal is for facilities to show a good faith effort in the collection of the patient’s current medication list.2Organizations must also show that the patient has been informed of the importance of maintaining an accurate medication list and a comparison of medications taken with the newly prescribed medications has been made to ensure there are no duplications, omissions, or interactions and that there’s a need to continue current medications.

The process

According to The Joint Commission standards, medication reconciliation should occur at the time that the patient enters the hospital or is admitted. The information should include dosage, route, and frequency. The patient and/or the family should be included in obtaining this information. All medications ordered while the patient is in the hospital should be compared with this list to ensure that there are no duplications, omissions, adjustments, and/or contraindications.2 Upon transfer within the facility, the provider handing off the patient should ensure that the receiving provider has an up-to-date reconciled medication list and understands it. Medication reconciliation must also occur when the patient is transferred to another facility or discharged home.2 The last part of the medication reconciliation process addresses areas in the hospital that have contact with patients for a short period of time. Identifying medication discrepancies is an important and necessary first step in this process.4 (See The medication reconciliation process.) 

Potential problems 

Medication reconciliation is only as accurate as the initial list of medications obtained. One question is: How can hospitals obtain an accurate list? There are multiple issues that surround obtaining an accurate list of medications, such as patients obtaining medications from multiple pharmacies, hospitals, and physicians; the medication list supplied by patients doesn’t always contain all the medications patients are taking; many lists provided by patients have wrong dosages, discontinued medications, and are missing new prescriptions; and ineffective communication may occur between healthcare providers.4,5 For example, there may be a lack of communication from a primary physician to the admitting hospitalists on duty when a patient is admitted through the ED. Another issue is physicians writing a prescription for one strength of medication and instructing patients to take half a tablet daily to help save money. 
The majority of patients who present to hospitals are unsure what medications they take.5 A large number of patients don't bring medication bottles with them to the hospital and/or bring discontinued medications.6 Patients fail to keep an accurate, updated list of medications. ED staff and admitting nurses frequently fail to obtain an accurate history due to busy environments and lack of time. Another problem is staff members not being properly trained to obtain an accurate, detailed medication history.7 The physician caring for the patient in the hospital frequently isn't the patient's primary physician but may be a surgeon and/or specialty physician. Physicians may also fail to thoroughly review the medication list obtained on admission for accuracy and order medication as listed. 

Suggested solutions

Medication reconciliation should first start with a detailed medication history. The medication history should be taken in a quiet, uninterrupted environment. This history should include: 

  • a list of medications the patient is currently taking
  • reasons why the patient is taking these medications
  • dosages
  • frequency
  • date and time last taken.
The history should also include a detailed list of the patient’s allergies and reactions that occur when medications are taken. It should be verified with at least one other source, such as the patient’s primary physician and/or pharmacy. After the list is verified, it should be reviewed with the patient one final time. A pharmacist should review the list obtained to ensure the medications listed make sense for the patient’s disease processes and risk of medication interactions. Upon completion of the medication history, the reconciliation process can begin. The completed medication list received during the thorough history should be compared with medications ordered on admission for omissions, duplicate orders, and contraindications. A pharmacy-driven multidisciplinary admission history and medication reconciliation process has been shown to reduce medication errors in academic settings and has the highest net benefits.8Research shows pharmacist are trained to understand medication usages better than other healthcare providers. Other research has shown that a pharmacist-nurse collaboration designed to identify and resolve medication-related discrepancies in patients transitioning from the hospital to the home has led to a significant improvement in medication discrepancy resolution.
After the medication list has been obtained and reviewed by the pharmacist, the physician needs to review the list and determine if the medications are appropriate for the patient. With increasing use of hospitalists, it’s important that physicians utilize hand-off communication, including medication reconciliation. Physician hand-off communication surrounding medication reconciliation is one area in which there has been little research. Effective communication between all healthcare providers is key to preventing medication errors, especially during hand-offs. 
Another key to successful medication reconciliation is maintaining an accurate, up-to-date medication list and providing patient education regarding the importance of following the list. This list should be updated at each transition of care to avoid discrepancies.4 Maintenance of an accurate and complete list of patient medications takes ongoing attentiveness by both the patient and the healthcare provider. Healthcare providers should provide patients with a laminated card with an updated list of medications at every encounter. Education must be provided for both the patient and the healthcare provider on the importance of maintaining the list. 
Development of multidisciplinary educational programs is also a key to making medication history taking and medication reconciliation a success. Education should include enhanced medication history taking skills and the importance of looking at the patient holistically.10Education must also include training on how to educate patients and families on maintaining an updated medication list. Following an in-depth education program, the medication reconciliation process should be audited and healthcare providers should be given feedback on their performance.


  1. World Health Organization. Assuring medication accuracy at transitions in care. Click here for web reference.
  2. The Joint Commission. Comprehensive Accreditation Manual for Hospitals Update 2. Oakbrook Terrace, IL: Joint Commission Resources, Inc.; 2011. 
  3. Joint Commission Resources. Medication Reconciliation Handbook. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources, Inc.; 2009. 
  4. Murphy CR, Corbett CL, Setter SM, Dupler A. Exploring the concept of medication discrepancy within the context of patient safety to improve population health. ANS Adv Nurs Sci. 2009;32(4):338-350. 
  5. Augustine J. Running on empty. Click here for web reference
  6. Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs. 2009;14(2):94–101. 
  7. Wortman SB. Medication reconciliation in a community, nonteaching hospital. Am J Health Syst Pharm. 2008;65(21):2047–2054. 
  8. Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge. Am J Health Syst Pharm. 2009;66(23):2126–2131. 
  9. Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Effectiveness of a pharmacist-nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care. Am J Health Syst Pharm. 2009; 66(22):2027–2031. 
  10. Cutter B. Verification of inpatient medication histories by pharmacy students. Am J Health Syst Pharm. 2009;66(11):988. 

By Shelly Brown, MSN, RN, PCCN This article originally appeared in the January 2012 issue of Nursing Management, © 2012 
Lippincott Williams & Wilkins. ​

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