Medication reconciliation is the formal process of reviewing a patient’s complete medication regimen at the time of admission, transfer, and discharge, and comparing it with the regimen being considered for a new care environment (PSNet 2019).

In essence, medication reconciliation aligns the correct medication with the correct patient. It’s closely tied to the concept of maintaining continuity of care.

Medication reconciliation is particularly important in transitional points of care, such as during admission, transfer and discharge.

When a person in care is moved between care environments, such as wards, hospitals and their home, a current and accurate list of their medicines should be provided to the health professional or carer who will be taking over that person’s care (Health.vic 2016).

Accidental changes to medicines often occur and for a vast range of reasons. For example, hospital staff may be unable to access a patient’s complete pre-admission medication list or could be unaware of very recent changes to their medication. Because of this, the new medication plan prescribed at discharge could accidentally exclude required medications, unnecessarily duplicate existing therapies, or list incorrect dosages (PSNet 2019).

These discrepancies make patients vulnerable to adverse drug events (ADEs) - one of the primary types of adverse events that occur following hospital discharge (PSNet 2019).

What Does Medication Reconciliation Look Like in Practice?

The following are integral to effective medication reconciliation:

• Obtaining, verifying and documenting a patient’s current prescriptions and over-the-counter medications. This encompasses medicines such as vitamins, supplements, eye drops, creams, ointments and herbal medicines. This process is to take place when a person is first admitted to hospital or seen in an outpatient setting.
• Considering the patient’s pre-admission or home medication list when ordering medicines during a hospital encounter and continuing medications as appropriate. Also, comparing the patient’s pre-admission or home medication list to ordered medicines and treatment plans in order to recognise unintended discrepancies.
• Verifying the patient’s home medications and discussing unintended discrepancies with their treating physician for resolution.
• Providing an updated medication list and making sure the patient understands the importance of managing their medication information when they are discharged from the hospital or at the end of an outpatient encounter.

(AHRQ 2012)

The MATCH Toolkit for Medication Reconciliation

Developed by America’s Agency for Healthcare Research and Quality (AHRQ), the MATCH (Medications at Transitions and Clinical Handoffs) toolkit lists the principles of an effective medication reconciliation process. These are:

• Developing a single medication list (a source of truth) that is shared across disciplines for documenting a patient’s current medications
• Clearly defining roles and responsibilities for each discipline involved in medication reconciliation
• Standardising and simplifying the medication reconciliation process throughout the organisation, removing any unnecessary redundancies
• Developing and implementing effective prompts or reminders for consistent behaviour
• Educating consumers, their families and caregivers on medication reconciliation and the important role they play in this process
• Ensuring the process design meets all relevant regulations
• Linking medication to other strategic goals or initiatives (such as accreditation) to bolster support for the medication reconciliation process.

(AHRQ 2012)

The Pharmacist’s Role

A systematic review conducted in 2016 found evidence that pharmacist-led processes could help to reduce medication discrepancies and potential ADEs at the time of hospital admission, in-hospital transitions of care (for example moving a patient into or out of intensive care), and at hospital discharge (PSNet 2019).

Additionally, a review published in 2013 found that pharmacist involvement in medication reconciliation prevented discrepancies and potential ADEs after discharge (PSNet 2019).

These studies aside, there is a noticeable gap in research as to the direct relationship between medication reconciliation and ADEs. While information technology solutions are being analysed, their influence in regards to preventing medication discrepancies and improving clinical outcomes is similarly underdeveloped (PSNet 2019).

Why is Medication Reconciliation So Vital?

Statistics show that medication errors are prevalent and a common cause of harm to patients.

• Up to two-thirds of medication histories have at least one error. Furthermore, up to one-third of these errors possess the potential to cause harm.
• Over 50% of medication errors occur during the transition of care.
• 85% of discrepancies in medication treatment are a result of poor medication history taking.

(Duguid 2012)

A ‘Best Possible’ Medication History

A 'best possible medication history' is an integral aspect of the medication reconciliation process. It is a comprehensive medication history obtained by a clinician that includes a thorough account of all regular medicines used, including non-prescription and complementary medicines, and is verified by multiple sources (Duguid 2012).

A structured process for taking this history, involving the patient and/or their carers and family, using a checklist to guide the interview, and that verifies the history with information from numerous sources, provides the most comprehensive assessment of the medicines a patient takes at home or in previous settings (Duguid 2012).

Conclusion

Applying a formalised and structured approach to medication reconciliation that is carried out in partnership with patients and carers, and is conducted in an environment of mutual accountability, has the potential to reduce the occurrence of medication errors that take place at cross-sections of care (Duguid 2012).

Medication reconciliation at transitional points of care: admission, transfer and discharge, is an important element of patient safety and prevents our health services from incurring economic burden (Duguid 2012).

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