Examining medication reconciliation from a perspective of safety



The impact of medication reconciliation efforts on patient safety remains largely unknown. Recently published, systematically reviewed evidence suggests that there are certain characteristics of medication reconciliation processes that correlate favorably with clinically important patient safety outcomes. These include utilizing a pharmacist-driven process and possibly focusing efforts on targeted, high-risk patient populations. Structured medication reconciliation across transitions in care that has support from administration has not only been linked to high-performing hospitals, but also has been identified as one area in which health information technology experts expect the most financial and clinical value in the future. Hospitals and managed care providers tasked with allocating resources aimed at optimizing patient safety while containing costs should carefully consider investing in this type of pharmacist-driven, medication reconciliation process.

Prior to 2005, the year the Joint Commission added medication reconciliation to its list of National Patient Safety Goals (NPSG), the term “medication reconciliation” had scarcely been seen in the published medical literature.1 In 2012 alone, the term can be found in over 200 published articles (source: PubMed and Embase), and in nearly 1,000 journal articles dating back to 2005. In 2010, the Society of Hospital Medicine published a consensus statement concerning medication reconciliation in which key principles and necessary first steps were described.2 Recently, the Agency for Healthcare Research and Quality (AHRQ) published a toolkit intended to guide practitioners and institutions in improving their medication reconciliation processes.In light of the NPSG set forth by the Joint Commission to maintain and communicate accurate patient medication information, as well as the support of organizations like AHRQ to carry out this goal, it would seem reasonable to assume that the benefits of medication reconciliation on improving patient safety must be incontrovertible. However, this assumption would be false.

Although there are varying descriptions of medication reconciliation, one of the most comprehensive definitions is the process of identifying and maintaining the most accurate and detailed list of all medications, both prescribed and non-prescribed, a patient is utilizing.4 The identification of these medications should include dosage and frequency, as well as documentation of any changes that have occurred through all healthcare encounters. This list of medications should be utilized to compare the physician’s admission, transfer, and/or discharge order in order to recognize any discrepancies, thus resulting in a complete list of medications, which can be accurately communicated to the next healthcare encounter. Given the layers of complexity in this definition, and the multiple transitions in care where errors could occur, it is easy to understand why unintended medication discrepancies across the continuum of healthcare are so prevalent.5–9

While the problem is well documented, the ability of medication reconciliation processes to prevent these discrepancies in a manner that has a clinically significant impact on patient safety is not well understood or documented in the literature. This statement may be surprising, given the significant investment that private and public healthcare sectors have made in health information technology (HIT) in recent years. Electronic health records (EHR) and health information exchange (HIE), two dominant forms of HIT, have long been thought to be a surefire solution to the problems of fragmented communication among diverse systems.10,11 While HIT has certainly aided in identifying the scope of the medication reconciliation problem, it has not proved to be the panacea that many had hoped.

The fundamental question remains: does medication reconciliation, as it is currently defined and practiced, really make patients safer? Despite the abundance of published literature on the topic of medication reconciliation, many of the studies that have attempted to validate the assertion that medication reconciliation has clinical value and improves patient safety are of relatively low scientific quality. Most are single-center studies, and the outcomes do not measure actual patient harms but rather rates of medication discrepancies and potential for adverse events. Some validity issues arise because many are not controlled studies, while other studies lack an interventional comparison group; most have either significant internal or external validity issues, and some have both. Two recently published systematic reviews on the topic of medication reconciliation have shed some needed light on the strength of the relationship between medication reconciliation and patient safety.

 A review by Mueller et al sought to identify the most effective medication reconciliation practices in the hospital setting.12 Twenty-six controlled studies were reviewed, although only 6 were judged to be of good quality. The included studies consistently found a reduction in medication discrepancies and potential and actual adverse drug events (ADE), but the benefits in post-discharge healthcare utilization were not as clear. The included studies used varied techniques to accomplish medication reconciliation, and it is clear that not all medication reconciliation processes are equal.

The review established that in order to reduce medication discrepancies, potential ADE and, to a lesser extent, actual ADE, a pharmacist-driven intervention is necessary. These types of interventions may include not only licensed pharmacists conducting medication reconciliation at patient admission or discharge, but also pharmacy residents and pharmacy technicians. By deploying a pharmacist-driven medication reconciliation technique, the review found that hospitals were able to reduce the odds of all hospital visits, including a 47% reduction in emergency department visits and an 80% reduction in drug-related readmission in the 12 months following discharge from the hospital. When pharmacy services were limited in medication reconciliation practices, there was no effect on health care use. Another characteristic that correlated with successful interventions was a focus on targeted, high-risk patient populations.

A more recently published systematic review supported by AHRQ focused specifically on how medication reconciliation across hospital-based transitions affected “clinically significant discrepancies” and hospital utilization after discharge.13 Eighteen studies representing 20 interventions were selected for the review, which found that only a few unintended medication discrepancies have clinical significance, and that most patients do not have any unintentional discrepancies. Unlike the review by Mueller, this study did not find a consistent correlation between high-risk patients and clinically significant unintentional discrepancies. However, some similarities between the 2 reviews were that most successful interventions relied heavily on pharmacists, and that medication reconciliation holds promise as a clinically significant intervention. Two other findings were that the benefits of resolving unintended discrepancies may not be seen until months after patients are discharged, and that the “bundling” of medication reconciliation with other multifaceted interventions may hold more promise than evaluating medication reconciliation as a stand-alone process.

A qualitative study sponsored by AHRQ sought to identify factors that may be related to better hospital performance in acute myocardial infarction (AMI) care, as measured by risk-standardized mortality rates.14 Eleven US hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates were visited on-site, and in-depth interviews were conducted with hospital staff. While there was no difference found between protocols and processes for AMI care between high- and low-performing hospitals, some important differences were the organizational approach, communication, and coordination among groups. Medication reconciliation practices were specifically identified as one of the key themes in high-performing hospitals.

In addition to contributing to better performance and patient safety, investing resources in medication reconciliation also may have a positive financial impact. The federal EHR Incentive Program to promote “meaningful use” will almost certainly continue to drive efforts to expand the use of HIT in all aspects of healthcare.15 A recent study by Kern et al sought to discover which components of EHR and HIE are most likely to drive financial savings across all care settings.16 After a thorough literature search and validation process, it was determined that enabling structured medication reconciliation between care settings was one of the high-scoring functionalities and should be prioritized by eligible providers and hospitals when choosing among those in the “meaningful use” menu set. Furthermore, it was suggested that these high-scoring functionalities be used to guide EHR and HIE implementation since they represent areas in which experts expect the most financial and clinical value.

This intersection of patient safety and financial impact is supported by another recently published systematic review, which attempted to examine safety improvement strategies in the acute care setting through the lens of comparative economic analyses.17 It concluded that pharmacist-led medication reconciliation to prevent potential ADE “dominated” a strategy of no reconciliation due to lower costs and better safety. A recent, prospective study conducted at Johns Hopkins utilizing a nurse/pharmacist–led medication reconciliation process reported a cost analysis in which resources, utilization, and cost savings were estimated.18 The cost of the intervention, which lasted for 15 months and served 2 resident-covered general medicine teams, was estimated to be $17,915. When the commonly cited estimate of 0.9% of all unintended medication discrepancies leading to an actual ADE (harm) was used, the intervention more than paid for itself, since each ADE was projected to cost $9,300, and 4.8 harmful discrepancies were estimated to have been prevented, resulting in an averted cost of $44,607.19

Hospital administrators and managed care decision-makers face difficult choices regarding how to allocate resources to ensure patient safety in the current climate of healthcare reform while meeting goals and benchmarks set forth by organizations like the Joint Commission. Recent evidence correlates meaningful outcomes related to patient safety with certain types of medication reconciliation practices. In order to perform medication reconciliation in a way that affects patient safety across transitions in healthcare, a significant investment of resources will likely be required, including the utilization of a pharmacist-driven process. Additional evidence suggests that making such an investment could put hospitals on a path that could align them with current top-performing hospitals, while potentially saving costs and staying ahead of the HIT “meaningful use” curve.


1. The Joint Commission. Improving America’s hospital: a report on quality and safety. http://www.jointcommission.org/assets/1/6/2006_Annual_Report.pdf. Accessed March 15, 2013.

2. Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5:477–485.

3. Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. (Prepared by the Island Peer Review Organization, Inc., under Contract No. HHSA2902009000 13C.) AHRQ Publication No. 11(12)-0059. Rockville, MD: Agency for Healthcare Research and Quality. Revised August 2012.

4. Institute for Healthcare Improvement. Medication reconciliation review. Available at: http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx. Updated July 12, 2011. Accessed March 15, 2013.

5. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424–429.

6. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004;61:1689–1695.

7. Pippins JR, Gandhi TK, Hamann C, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23:1414–1422.

8. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173:510–515.

9. Wong JD, Bajcar JM, Wong GG, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42:1373–1379.

10. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348:2526–2534.

11. Fricton JR, Davies D. Personal health records to improve health information exchange and patient safety. In: Henriksen K, Battles JB, Keyes MA, et al, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4: Technology and Medication Safety). Rockville, MD: Agency for Healthcare Research and Quality (US); 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK43760/.

12. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172:1057–1069.

13. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:397–403.

14. Curry LA, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med. 2011;154:384–390.

15. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363:501–504.

16. Kern LM, Wilcox A, Shapiro J, Dhopeshwarkar RV, Kaushal R. Which components of health information technology will drive financial value? Am J Manag Care. 2012;18:438–445.

17.  Etchells E, Koo M, Daneman N, et al. Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review. BMJ Qual Saf. 2012;21:448–456.

18. Feldman LS, Costa LL, Feroli ER, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012;7:396–401.

19. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:199–205.


Dr Daly is assistant professor of pharmacy practice, St. Louis College of Pharmacy, St. Louis; Dr Lee is clinical pharmacist, Missouri Baptist Medical Center, St. Louis.

The authors report no financial disclosures as related to products discussed in this article.



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