Making the case for medication reconciliation

ISMP Error Alert

Situation 1: Pamelor (nortriptyline) was prescribed for a newly admitted patient. While clarifying another order with the patient’s pharmacy several days later, a pharmacist learned that the patient had been taking Panlor (acetaminophen, caffeine, dihydrocodeine) at home, not Pamelor. Situation 2: Before discharge, Lexapro (escitalopram) was increased to 10 mg daily, but the patient’s discharge instructions listed 5 mg daily. When the error was noticed, a pharmacist called the patient, who had been cutting in half the 10-mg tablets provided with her new prescription.

These cases illustrate the outcomes of failed communication about prescribed medications during the vulnerable transition points of admission and transfers between care settings. The Institute for Safe Medication Practices (ISMP) and other organizations receive many such reports each week.

According to the Institute for Healthcare Improvement, poor communication of medical information at transition points is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in hospitals. This is precisely why the Joint Commission has focused the nation’s attention on reducing the risk of errors during these transition points through medication reconciliation.

A 2012 Joint Commission National Patient Safety Goal requires facilities to reconcile medications across the continuum of care. Here are the steps ISMP recommends for implementing this process.

Obtain a medication history

Obtain the most accurate list possible of the patient’s current medications at the beginning of an episode of care. This includes the name of prescription and OTC medications (including herbal and dietary supplements), the dose, route, frequency, and indication/purpose. Be sure to include all medications taken on a scheduled basis and on an as-needed basis. Most organizations use a specific form for this purpose, on which an assessment of patient adherence with drug therapy and the source of the medication history information can be documented. Besides the patient and family, other sources of information may include visual inspection of the patient’s medications brought into the facility, previous medical records, and the patient’s pharmacy and physician.

Distribute the list

As soon as the list is reasonably complete, have prescribers review and act upon each medication on the list while prescribing the patient’s admission medications. Take the following steps:

  • Reconcile and resolve discrepancies—duplications, unclear information, omissions, contraindications, and changes.
  • Have a second person compare the prescribed admission medications with those on the medication history list, and resolve discrepancies.
  • Reconcile again upon transfer and discharge. Each time a patient moves from one setting to another, review previous medication orders alongside new orders and plans for care, and resolve discrepancies.
  • When the patient is discharged, the reconciled list of admission medications must be compared against the physician’s discharge orders along with the most recent medication administration record. Any differences must be fully reconciled before discharge, and a complete updated medication list should be provided to the patient.

Share the list

Communicate a complete list of the patient’s medications to the next provider of service when transferring a patient to another setting, service, practitioner, or level of care within or outside the organization. This includes sending a list of medications prescribed upon discharge from the hospital to the patient’s primary care physician, as well as encouraging patients to share the list with their pharmacy. Patients should update their medication list continuously and always have it readily available.

The Joint Commission requires hospitals and ambulatory health care facilities—including primary care providers and nonsurgical settings such as medical group practices and community health centers—to initiate this type of medication reconciliation process now. With all health care settings involved in the process, an accurate medication history and reconciliation of prescribed therapy are feasible. More information is available from the Joint Commission at