Medication Reconciliation

Medication Reconciliation
in the Hospital
What, why, where, when, who and how?
Olavo Fernandes and Kaveh G. Shojania

Abstract

A
Medication reconciliation arose as the solution to the t the monthly management meeting of a large urban
well-documented patient safety problem of unintention- hospital, the head of patient safety announces: “We had
ally introducing changes in patients’ medication regimens a critical incident last week. A patient was readmitted
due to incomplete or inaccurate medication information at two days after discharge with severe hypoglycemia. The
transitions in care. Unfortunately, medication reconciliation treating team discharged the patient on a new insulin regimen
has often been misperceived as a superficial administrative without realizing that the patient also had insulin 30/70 at home.
accounting task with a “pre-occupation with completing The patient continued to take her previous regimen as well as the
forms,” resulting in the implementation of ineffective new one, and was found unresponsive by her husband. She’s in the
processes. In this article, the authors briefly review the ICU and probably will have permanent neurological deficits.” After
evidence supporting medication reconciliation but focus various sighs and exclamations from the executives around the table,
more on key practical questions regarding the elements of the chief medical officer asks, incredulously, “Why didn’t this get
an effective medication reconciliation process: what it should picked up by medication reconciliation?” Before anyone can answer,
consist of, where and when it should occur, who should carry the executive adds: “We had that other case six months ago in which
it out and how hospitals should implement it. The authors a patient was discharged without restarting his Coumadin, and he
take the why of medication reconciliation to consist not just ended up having a stroke. We implemented medication reconcilia-
of the professional obligation to avoid causing harm, but also tion last year: why is this still happening?”
of a rational self-interest on the part of healthcare leaders. The answer to this executive’s question is that care transitions
The authors argue that, rather than wasting time imple- represent such an error-prone process that, even with robust
menting a nominal reconciliation process, we should invest medication reconciliation, catastrophic cases such as these can
time and energy in a more robust and effective strategy, and still occur. Moreover, the vast majority of hospitals do not have
they address specific practical questions that arise in such a robust medication reconciliation process in place, so these
an effort. events can continue to occur with considerable frequency.

42 Healthcare Quarterly Vol.15 Special Issue 2012

 Olavo Fernandes and Kaveh G. Shojania Medication Reconciliation in the Hospital

In this article, we use the

fIGURE 1.
existing literature, as well as Overview of medication reconciliation – what, where, when and how
results from our own research
and experiences as clinicians,
as pharmacist (O.F.) and a
physician (K.S.) to address key Previous
practical questions regarding Patient/ Government
Medication Patient
Family Medication
effective medication reconcili- Vials/List Health
Interview Database
ation: what it should consist Records
HOME
of, where and when it should
Sources of Medication Information
occur, who should carry it
out and how hospitals should
implement it. In terms of why,
we do not formally review the
evidence supporting medica- Admission Reconciliation Best Possible
tion reconciliation; however, Medication History
we do briefly summarize key (BPMH)
studies that indicate the likely
HEALTHCARE FACILITY
impact on patient safety.
Medication Ordered during
Admission and Internal Transfer
Why Implement
Medication
Decision to Discharge
Reconciliation?
Transitions from one health-
care setting to another –
whether from an intensive care Best Possible Medication
unit to a general ward or from Discharge Plan (BPMDP)
Discharge Reconciliation
a rehabilitation facility to the
patient’s home – increase the
risks of adverse drug events
and can contribute to avoid-
able hospital visits (Dedhia
et al. 2009; Fernandes 2009; HOME
Jack et al. 2009; Ong et al. Reconciled Physician Patient
2006). For instance, incom- Discharge Discharge Medication
plete or inaccurate medication Prescriptions Summary Schedule
information can introduce
changes to patients’ outpa- BPMDP Communicated to Patient and Next Provider of Care
tient medication regimens
Source: Adapted from Pharmacy Practice 2009;25(6):26 with permission.
that were not intended by
hospital-based physicians.
Two common unintended
medication changes are omissions – pre-admission medications were judged to have the potential to cause moderate to severe
are omitted from hospital orders and therefore not continued discomfort or clinical deterioration. Because many unintended
after discharge – and commissions – previous medications medication discrepancies are relatively minor, the better studies
that patients discontinued prior to admission are inadver- have assessed the likely clinical impact of the discrepancies identi-
tently re-initiated in the hospital and therefore continued upon fied by medication reconciliation (Gleason et al. 2004; Lalonde
discharge (Tam et al. 2005). In one study of 151 hospitalized et al. 2008; Nickerson et al. 2005; Schnipper et al. 2009; Varkey
medical patients (Cornish et al. 2005), 54% of patients had at et al. 2007; Vira et al. 2006). Despite varying definitions of
least one unintended discrepancy between their hospital and clinical impact, these studies all identify a category that might be
outpatient medication regimens, and 39% of these discrepancies called “clinically important” discrepancies – unintended changes

Healthcare Quarterly Vol.15 Special Issue 2012 43

Medication Reconciliation in the Hospital Olavo Fernandes and Kaveh G. Shojania

to patients’ medica-
TABLE 1.
tions with a reason-
Medication reconciliation in varying levels of intensity, as seen in published studies
able risk of some
harm. Rates for these Level Key Components Published Examples
clinically important
unintended discrep- Bronze BPMH with admission reconciliation Cornish et al. 2005; Kwan et
ancies range from al. 2007
a low of 0.25 per Silver Bronze level + reconciliation at discharge by prescriber only ± Schnipper et al. 2009; Wong
patient to a high electronically generated discharge prescription et al. 2008
of 0.97. The best
study to date – the Gold Silver level + discharge reconciliation is inter-professional (e.g., Cesta et al. 2006; Dedhia
prescribing physician and pharmacist collaboration) + electronically et al. 2009; Schnipper et
only randomized generated discharge prescription al. 2009
controlled trial
comparing medica- Platinum Gold level + attention to broader medication management Al-Rashed et al. 2002;
tion reconciliation issues (e.g., appropriateness of agents, safety and effectiveness Dedhia et al. 2009;
assessment) + medication counselling prior to discharge (including Makowsky et al. 2009;
with usual care with discussion of medication changes) + provision of patient-friendly Murphy et al. 2009;
an intervention reconciled medication schedules upon discharge Nazareth et al. 2001
that involved inter-
professional process Diamond Platinum level + additional elements, such as Gillespie et al. 2009; Jack
• post-discharge follow-up phone call to patient by hospital clinician et al. 2009; Karapinar-Çarkit
redesign from admis-
(e.g., nurse or pharmacist) et al. 2009; Schnipper et al.
sion to discharge • communication of medication changes with rationale directly to 2006; Walker et al. 2009)
(Schnipper et al. community pharmacy and primary care physician
2009) – reported a
BPMH = best possible medication history.
relative reduction
in potential adverse
drug events of 28% (95% confidence interval 1.0–48%). process for interviewing the patient (or family) and (2) a review
These studies of the impacts of medical reconciliation on of at least at least one other reliable source of information (e.g.,
clinically significant events all involve key roles for pharma- a provincial medication database, an inspection of medication
cists. Accreditation standards do not stipulate involvement by vials or contact with the community pharmacy) to obtain and
pharmacists (Accreditation Canada 2011, Joint Commission verify patient medications (prescribed and non-prescribed) (Safer
2011), and staffing constraints probably limit the degree to Health Care Now! 2011). In practice, however, medication histo-
which pharmacists perform medication reconciliation outside ries fall short of these recommendations, with clinicians skipping
academic medical centres. Thus, medication reconciliation as the time-consuming step of actually speaking with the patient to
implemented in most hospitals does not correspond to the inter- verify medications. Reconciling a suboptimal medication history
vention for which the literature provides support. with medication orders does nothing to improve care and may
even “hard-wire” unintentional discrepancies. Finally, efforts
What Is Medication Reconciliation? to obtain a BPMH face the many challenges associated with
Initial conceptions of medication reconciliation have evolved patients who maybe unfamiliar with their medications.
into a robust system for reducing potential adverse drug events The number and intensity of medication reconciliation activ-
and risks for unnecessary subsequent care (Figure 1 [High 5s ities may legitimately vary between hospitals and even clinical
2009]; Fernandes 2009; World Health Organization 2006). areas within a hospital. Table 1 outlines a proposed continuum
Unfortunately, medication reconciliation has often been of varying levels of medication reconciliation intensity, from
misperceived as a superficial administrative accounting task bronze—just a BPMH and reconciliation, the current national
with a “pre-occupation with completing forms” (Boockvar et accreditation indicator in Canada (Accreditation Canada.
al. 2011). When conducted as intended, medication recon- 2011)—through to silver, gold, platinum and diamond. The more
ciliation is a conscientious, patient-centred, inter-professional advanced levels of medication reconciliation involve progressions
process that supports optimal medication management in inter-professional collaboration, integration of medication
(Greenwald et al. 2010). reconciliation into discharge summaries and prescriptions, and
The best possible medication history (BPMH) provides the delivery of more comprehensive medication education to
the cornerstone for medication reconciliation. It differs from patients. In principle, individual patients might appropriately
a routine medication history in that it involves (1) a systematic receive different levels of medication reconciliation, from bronze

44 Healthcare Quarterly Vol.15 Special Issue 2012

 Olavo Fernandes and Kaveh G. Shojania Medication Reconciliation in the Hospital

to platinum, given their different risks for adverse drug events. discharge process, but the time pressure at admission, especially
In practice, hospitals may choose a specific degree of medication for acutely ill patients, presents challenges for obtaining a
reconciliation for all patients in a given clinical area. BPMH. In practice, hospitals deal with the time pressure issue
by expanding “on admission” to mean within 24–48 hours of
Where Should Medication Reconciliation admission. This solves the time pressure problem but misses
Occur? the opportunity to have the medication reconciliation support
Literature on medication reconciliation in ambulatory settings has the process of creating medication orders at admission. As with
begun to emerge (Bayoumi et al. 2009; Fernandes 2009; Varkey the discharge process, not integrating medication reconciliation
et al. 2007), but most studies remain focused on the hospital. into a relevant clinical process (e.g., creating orders at admis-
Within the in-patient arena, should hospitals target any sion) may foster the misperception of medication reconciliation
specific clinical area first? The extent to which patients in some as extra work that exists for purely administrative reasons.
clinical areas benefit more from medication reconciliation than On balance, starting the medication reconciliation process
patients in others (e.g., general medicine versus surgery) remains at or soon after admission may ultimately save time. Even if
unclear. (Realistically, the potential benefit probably depends admission reconciliation does not directly generate admission
on the number and type of medications taken by patients, not orders, the discharge process will be more accurate and efficient
the clinical service.) Thus, rather than choosing to focus on if a BPMH already exists. Also, the Accreditation Canada
clinically defined patient groups, many hospitals choose to indicator, a natural incentive, is currently focused on admis-
target patients admitted through the emergency department sion. Importantly, these ideas are not mutually exclusive. A
and elective patients, typically in surgery. Focusing on elective “phased-in” approach that starts on admission, sustains gains
patients offers the advantage of proactively conducting the throughout hospitalization and finishes at discharge may make
BPMH in a controlled setting such as a pre-admission clinic the most sense.
(Kwan 2007). That said, the emergency department represents
a much larger gateway for hospitalized patients, and the strate- The Who’s Who of Medication Reconciliation
gies used for medication reconciliation in a pre-admission clinic Should hospitals target all admitted patients or “high-risk” patients
may not translate well to the busy, time-pressured setting of the only? With limited human resources and hospitals struggling to
emergency department. fully implement medication reconciliation across the continuum,
it may seem natural to target patients who will most benefit from
When Should Medication Reconciliation medication reconciliation. However, evidence-informed criteria
Occur? for high-risk patients’ medication reconciliation remain unclear
Should hospitals first target admission, discharge or internal trans- at this time. Some authors have suggested that medication
fers? Some studies have highlighted serious medication risks at reconciliation candidates can be focused by age (over 65 years
internal transfer points, such as from intensive care to a ward old) or number of medications (more than four) (Coffey et al.
(Santell 2006). Realistically, though, most hospitals initially 2009; Gleason et al. 2010). Others have proposed that “high risk
choose to target medication reconciliation at admission or criteria” include factors such as frequent hospitalizations, high-
discharge. Both options involve implementation issues, and alert medications, chronic diseases prone to frequent medication
determining the optimal choice for a particular hospital is changes and patients with a large number of in-hospital medica-
challenging. Ultimately, some form of discharge reconciliation tion changes (Rumball-Smith and Hider 2009). Narrowing the
needs to be present – after all, the main purpose of medication scope of medication reconciliation promises a “quality job” for
reconciliation is to avoid unintended medication errors created targeted patients versus a “superficial effort” for all.
by hospitalization. The key challenge faced by discharge recon- Despite the plausibility of this approach, an important
ciliation is integrating it into the general discharge process, practical argument in support of medication reconciliation for
which already involves multiple activities on the part of physi- all patients is that accurately identifying high-risk patients (e.g.,
cians, nurses, pharmacists and other health professionals. It based on the number or type of medications) often requires a
may be tempting to simply provide a medication reconciliation proper BPMH process. Moreover, in some settings (e.g., medical
form or letter with a summary of medication changes. However, wards), screening for a high-risk status may not practically elimi-
disconnecting medication reconciliation from related discharge nate many patients. Finally, patients who are considered low risk
processes, such as preparing discharge summaries and prescrip- at admission may have changes made to their home medication
tions, may minimize its full benefit and give rise to the false regimens later in their hospitalization that would elevate their
impression that medication reconciliation is not a clinically risk status. For all these reasons, Accreditation Canada’s focus
relevant process and just adds to clinicians’ work. on applying medication reconciliation to all admitted patients
Reconciliation at admission avoids the complexities of the seems reasonable. That said, a given hospital may recognize that

Healthcare Quarterly Vol.15 Special Issue 2012 45

Medication Reconciliation in the Hospital Olavo Fernandes and Kaveh G. Shojania

certain wards generally treat patients with short medication lists by reducing redundancy in the traditional approach of physi-
and for whom few changes in pre-hospital medications occur. cians and nurses all conducting individual medication histories.
In such cases, a lower-level version of medication reconciliation Regardless of which professionals carry out medication
(see Table 1) may be justified. reconciliation, patients remain essential partners in the process.
Who should optimally lead medication reconciliation activi- Even completely perfect reconciliation will serve little purpose
ties? Some argue that, based on their educational training and if patients do not understand their new medication regimens.
expertise, hospital pharmacists are uniquely positioned to lead Thus, the higher levels of medication reconciliation shown in
and support patients and inter-professional teams with medica- Table 1 include discharge medication counselling to patients.
tion reconciliation (Fernandes and MacKinnon 2008) and that Other advanced features include the use of patient portals/kiosks
this may result in better accuracy and clinical and economic to actively engage patients in the BPMH process and support a
outcomes (Bond and Raehl 2007; Carter et al. 2006; Coffey et patient-accessible medication record (Bassi et al. 2010).
al. 2009; Kaboli et al. 2006; Tam et al. 2005). Karnon et al.
(2009) conducted a cost-effectiveness analysis suggesting that How to Implement Medication Reconciliation
pharmacist-led reconciliation yields the highest expected net One of us (K.S.) has led a study of the experiences of 25 adult
benefits and a probability of being cost-effective of more than and pediatric healthcare institutions across Canada with imple-
60% by a quality-adjusted life year value of £10,000. menting medication reconciliation. The formal analysis of the
However, there can be problems with pharmacists leading interviews with 74 nurses, pharmacists, physicians, patient safety
reconciliation. First, many wards do not have clinical pharma- officers, project managers and senior executives has not yet been
cists, and most hospitals do not have 24/7 pharmacy service or published, but some key themes are summarized here. First, what
enough pharmacist resources to complete and sustain medica- counts as medication reconciliation varies widely. Areas of varia-
tion reconciliation at all interfaces. Limited pharmacist resources tion included who conducted the medication history and how
may thus result in a target of only complex patients. A feasible it was taken, the number of histories completed, the role of the
alternative adopted by some hospitals is the use of pharmacy medication order and which patients’ medications were recon-
technicians and students to support medication reconcilia- ciled. Some of this variation reflects understandable decisions
tion (Lam et al. 2009; Mersfelder and Bicketl 2008; van den in response to local implementation challenges. However, some
Bernt et al. 2009). Regardless of the profession, a key factor is variation included clearly suboptimal processes, such as the
having the clinician receive formal practical training on how to absence of a systematic approach to history taking and obtaining
systematically and efficiently conduct a BPMH (Boockvar et al. medication information from more than one source.
2011; Greenwald et al. 2010; Safer Health Care Now! 2011). The focus of this study, however, was on the practical
challenges encountered in implementation. These barriers
included the following:
Regardless of which professionals
carry out medication reconciliation, patients • Substantial underestimation of the time and resources
remain essential partners in the process. required to implement medication reconciliation
• Resistance from front-line staff due to impacts on workload
and work flow (physicians sometimes resisted even
Formal BPMH training also promotes professional “trust” in independent of such impacts)
this critical shared information. • A lack of implementation/change management experience
Second, if pharmacists lead, there is a danger that other • Turnover on the core implementation team
health disciplines will divest themselves of the patient respon- • Limited resources for ongoing education and support to
sibility linked to this critical activity. Interviews with staff at sustain the implementation
hospitals across Canada as part of an ongoing study conducted • Too rapid implementation, as a result of pressure due to
by one of us (K.S.) confirmed this concern in some hospitals: accreditation, resulting in a poorly configured process
the focus on the pharmacists/pharmacy technicians risks losing
sight of medication reconciliation as a shared inter-professional Not surprisingly, interviewees repeatedly identified that real
accountability. A recent US panel of stakeholders, representing support from senior management in appropriately resourcing
professional, clinical, healthcare quality, consumer and regula- teams and implementation efforts was key to success. Other
tory organizations, achieved consensus that hospital-based facilitators included having physician “champions,” inter-
medication reconciliation should employ an inter-professional professional implementation teams and contact with other insti-
team approach as the ideal (Greenwald et al. 2010). Moreover, tutions to share and learn from implementation efforts (e.g., a
a coordinated, inter-professional process can improve efficiency formal collaborative, such as Safer Healthcare Now!)

46 Healthcare Quarterly Vol.15 Special Issue 2012

 Olavo Fernandes and Kaveh G. Shojania Medication Reconciliation in the Hospital

TABLE 2.
Summary of pros and cons for key issues in medication reconciliation in acute care

Question and Position Considered Pros Cons

Where? • ED is the most common gateway for admissions in most • Starting in surgical pre-admission clinics for
Where should hospitals implement hospitals elective surgery patients allows for “pro-active”
medication reconciliation? • Unclear whether one clinical service has clear benefits medication reconciliation for most patients (BPMH
Position considered: over another, so makes sense to look at all patients completed in advance of admission orders) vs.
Hospitals should initiate in the ED. admitted through ED gateway “reactive” medication reconciliation in the ED
• Absence of published evidence of clear medication • May be better to pick a clinical service with a high
reconciliation benefit for non-admitted ED patients over rate of medication-related readmissions vs. all
admitted patients admitted patients in the ED

When? • Prevent discrepancies in hospital and beyond – • May be better to target select patients at discharge
Which patient transition of care discrepancies on admission are propagated through interface rather than all admitted patients
should hospitals target first: hospital stay to discharge so better to correct them from • Discharge medication reconciliation may
admission, discharge or internal the beginning reduce clinically meaningful outcomes such as
transfer? • Saves time: quality discharge medication reconciliation readmissions
Position considered: more efficient and accurate if a BPMH already exists • Patients may be at higher risk for adverse events
Hospitals should target the admission • Accreditation Canada national indicator focuses on outside the confines of hospital setting
transition first for implementing admission • Limited evidence that mortality risk is higher at
medication reconciliation. internal-transfer interface (Santell 2006)

Who? • Targeting all patients may save time – takes extra time • With limited resources, better to target medication
Should hospitals target all admitted and effort to screen for “high-risk” criteria (time better reconciliation resources to patients who will derive
patients or “high-risk” patients only? directed to medication reconciliation care) the most benefit
Position considered: • Often can only truly ascertain appropriate risk after a • Clear, evidence-informed “high-risk” patient
Hospitals should aim to complete proper BPMH (i.e., number of medications or high-alert populations for medication reconciliation–related
medication reconciliation for all drugs) adverse drug events are unclear at this time, but
admitted patients. • Accreditation Canada’s focus is on “all admitted more definitive evidence evolving in this area
patients”
• Risk stratification point may only account for risk factors
on admission, but other important risk factors may occur
later (i.e., number of changes in hospital to home regimen)

Who? • Pharmacists may lead admission reconciliation, with • Danger that if pharmacists lead, other health
Which healthcare discipline prescribers (physicians and nurse practitioners) leading disciplines divest themselves of the responsibility
should optimally lead medication discharge linked to this critical activity
reconciliation patient activities? • Limited studies to suggest improved accuracy with • Not enough pharmacist resources to complete and
Position considered: pharmacist medication reconciliation sustain medication reconciliation – consider nurses
Hospital pharmacists should lead and or pharmacy technicians or healthcare students
perform medication reconciliation • Pharmacists often not available 24/7
activities for the inter-professional • Limited pharmacist expertise should be more
team. appropriately targeted only to complex and high-
risk patients

How? • Electronic systems may save clinicians time and lessen • Electronic systems often require full CPOE
Should hospitals use paper-based tedious work implementation – which most hospitals do not yet
or electronic-based resources for • They allow for quick “conversion” of BPMH to have in place
medication reconciliation? admission orders • They introduce unique risks and may create a false
Position considered: • Information may pre-populate admission or discharge sense of accuracy – “hard-wire” mistakes
Hospitals should use electronic- prescription orders • May have to address multiple system integration
based platforms to support • Easy patient tracking for team regarding who has issues to be effective
inter-professional medication received medication reconciliation and for monthly • May add unnecessary complexity vs. a simple
reconciliation. hospital reporting paper form to facilitate medication reconciliation
• System may facilitate “electronic reconciliation” to
trigger identification of discrepancies
• Aligns medication lists from different points in time on
one screen to visualize together

BPMH = best possible medication history; CPOE = computerized physician order entry; ED = emergency department.

Healthcare Quarterly Vol.15 Special Issue 2012 47

Medication Reconciliation in the Hospital Olavo Fernandes and Kaveh G. Shojania

Our interviews also revealed that, despite the accreditation Bayoumi, I., M. Howard, A.M. Holbrook and I. Schabort. 2009.
requirement, many hospitals have not yet fully disseminated “Interventions to Improve Medication Reconciliation in Primary
Care.” Annals of Pharmacotherapy 43: 1667–75.
admission to discharge medication reconciliation beyond one
Bond, C.A. and C.L. Raehl. 2007. “Clinical Pharmacy Services,
or two pilot units, a finding confirmed anecdotally in discus- Pharmacy Staffing, and Hospital Mortality Rates.” Pharmacotherapy
sion with colleagues across the country. Many of these imple- 27: 481–93.
mentation lessons thus remain relevant as hospitals struggle Boockvar, K.S., S.L. Santos, A. Kushniruk, C. Johnson and J.R.
to spread and sustain quality medication reconciliation. Two Nebeker. 2011. “Medication Reconciliation: Barriers and Facilitators
specific practical decisions related to implementation also merit from the Perspectives of Resident Physicians and Pharmacists.” Journal
consideration, namely, whether to turn the medication recon- of Hospital Medicine 6: 329–37
ciliation document into the admission orders (or the prescrip- Carter, M.K., D.M. Allin, L.A. Scott and D. Grauer. 2006. “Pharmacist-
tion at the time of discharge) and whether to strive for an Acquired Medication Histories in a University Hospital Emergency
Department.” American Journal of Health-System Pharmacists 63:
electronic process. Table 2 presents some of the pros and cons 2500–3.
related to these issues. Overall, hospitals should recognize that Cesta, A., J.M. Bajcar, S.W. Ong and O.A. Fernandes. 2006. “The
the successful implementation and maintenance of high-quality EMITT Study: Development and Evaluation of a Medication
medication reconciliation practices, to the degree that they Information Transfer Tool.” Annals of Pharmacotherapy 40: 1074–81.
effectively prevent actual patient adverse events, require careful Coffey, M., P. Cornish, T. Koonthanam, E. Etchells and A. Matlow.
inter-professional and organizational planning along with effec- 2009. “Implementation of Admission Medication Reconciliation
tive change leadership. A number of hospitals in North America at Two Academic Health Sciences Centres: Challenges and Success
Factors.” Healthcare Quarterly 12: 102–9.
have published their successful medication reconciliation
implementation journeys and valuable practical lessons learned Cornish, P.L., S.R. Knowles, R. Marchesano, V. Tam, S. Shadowitz,
D.N. Juurlink and E.E. Etchells. 2005. “Unintended Medication
(Coffey et al. 2009; Murphy et al. 2009; Schnipper et al. 2009). Discrepancies at the Time of Hospital Admission.” Archives of Internal
Medicine 165(4): 424–9.
Conclusion Dedhia, P., S. Kravet, J. Bulger, T. Hinson, A. Sridharan, K. Kolodner,
Doing the bare minimum when it comes to medication recon- S. Wright and E. Howell. 2009. “A Quality Improvement Intervention
ciliation – just putting in place enough of a process to meet to Facilitate the Transition of Older Adults from Three Hospitals
Back to Their Homes.” Journal of the American Geriatrics Society 57:
accreditation standards – will do little to prevent catastrophic 1540–46.
cases, such as the ones described at the outset, from continuing
Fernandes, O. 2009. “Medication Reconciliation – Practical Tips,
to occur. Moreover, the occurrence of such cases will cause Strategies and Tools for Pharmacists.” Pharmacy Practice 25(6): 24–32.
frustration (never mind risk management issues), given that
Fernandes, O.A. and N.J. MacKinnon. 2008. “Point Counterpoint –
implementing even a fairly superficial medication reconciliation The “Pro” Side – Is The Prioritization of Medication Reconciliation
process consumes substantial institutional time and resources. as a Critical Activity the Best Use of Pharmacists’ Time?” Canadian
We argue that, rather than wasting time implementing a Journal of Hospital Pharmacy 61: 149–50.
nominal medication reconciliation process, hospitals should Gillespie, U., A. Alassaad, D. Henrohn, H. Garmo, M. Hammarlund-
invest additional time and energy in a more robust effective Udenaes, H. Toss et al. 2009. “A Comprehensive Pharmacist
Intervention to Reduce Morbidity in Patients 80 Years or Older.”
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to the what, where, when, who, why and how of implementing
Gleason, K.M., J.M. Groszek, C. Sullivan, D. Rooney, C. Barnard and
medication reconciliation. G.A. Noskin. 2004. “Reconciliation of Discrepancies in Medication
Histories and Admission Orders of Newly Hospitalized Patients.”
Acknowledgement American Journal of Health-System Pharmacists 61(16): 1689–95.
Our thanks go to Michelle Baker, BScPhm, of the University Gleason, K.M., M.R. McDaniel, J. Feinglass, D.W. Baker, L. Lindquist,
Health Network, for developing Table 1. D. Liss and G.A. Noskinl. 2010. “Results of the Medications at
Transition and Clinical Handoffs (MATCH) Study: An Analysis
of Medication Reconciliation Errors and Risk Factors at Hospital
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Olavo Fernandes, BScPhm, PharmD, is a member of the
Nickerson, A., N.J. MacKinnon, N. Roberts and L. Saulnier. 2005.
“Drug-Therapy Problems, Inconsistencies and Omissions Identified Department of Pharmacy, University Health Network, and
during a Medication Reconciliation and Seamless Care Service.” Leslie Dan Faculty of Pharmacy, University of Toronto; and
Healthcare Quarterly 8(Special Issue): 65–72. the University of Toronto Centre for Patient Safety, in Toronto,
Ontario. You can contact him at 416-340-4800, ext. 6436, or by
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Medication Reconciliation. Prevention of Adverse Drug Events: How-To

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