An academic hospitalist group's take on best practices for medication reconciliation

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking and comparing that list against the physician’s orders at each transition of care.

Zigian Wang

With the rise of hospitalists, in an inpatient setting, this process is often handled and overseen by hospital medicine specialists or hospitalists during each patient encounter at the time of admission, transfer and discharge.

Although this is a mundane and necessary component of each hospitalization, it carries substantial and rather astonishing statistics on how it can go awry in the form of potential adverse drug events (ADEs). Discrepancies are highly prevalent, with up to 67% of inpatients having at least one error in their order history at the time of admission, according to a report by Tam and colleagues. And these discrepancies are an important contributor to ADEs. Omission is the most common type of discrepancy. In one study by Abdulghani and colleagues, there is an estimated 14% of discrepancies labeled as Class 3 discrepancy, which is defined as having potential to result in severe discomfort or clinical deterioration. Although most errors occur during admission medication reconciliation, most potential adverse drug events occur during discharge medical reconciliation.

Kevin D'Mello

There are several valid sources of information from which medication history could be gathered. Patient, family and caregiver, if reliable, all can give clinicians information. The patient’s own medication bottles, if present, can certainly be useful. The patient’s pharmacy can be contacted for a list of medications and dispense reports. And the patient’s primary care or specialty provider’s office can also be contacted for cross-reference. Additionally, existing medical records and external records can be looked up not only for medication history gathering but also with reconstruction of medical history, especially when patients for one reason or another could not offer reliable information.

Although there is a plethora of sources of information, the challenge remains to gather updated medication information in both an accurate and timely manner in the setting of clinical practice. The Agency for Healthcare Research and Quality proposed the concept of “one source of truth.” It recommends an idealized medication reconciliation process design, one that “should center on the concept of a single list to document [a] patient's current medications. This list should be shared and utilized by all physicians, nurses, pharmacists and others caring for the patient.”

Elizabeth A. Cerceo

Countercurrent to the objectives mentioned earlier, there are several well-identified barriers to producing a high-quality medication reconciliation. These include unreliable sources of medication information, competing tasks for providers’ time and attention, lack of electronic medical records cross talk and lack of identification of individual roles and responsibilities.

Although this is a complicated endeavor, here are some general recommended practices to follow and to avoid when conducting medication reconciliation:

Do’s

• Do try to ask open-ended questions, such as, “What medications do you take? What do you take for your asthma?”
• Do try to cross-reference at least one other source of information in addition to patient interviews alone.
• Do try to “get it right the first time.” If admission medication reconciliation is done properly, then it makes for a much easier workflow downstream, such as during a patient transfer or discharge. Fewer admission errors equal fewer discharge errors, and ultimately, fewer potential ADEs.

Don’ts

• As obvious as it sounds — but still worthwhile to emphasize — do not skip medication reconciliation. It is a must-do step during each and every transition of care.
• Do not ask “yes or no” questions, such as “do you take albuterol?”
• Do not read off a medication list to patients, such as, “So I see on file that you take carvedilol, lisinopril, spironolactone... ”
• Do not multitask when conducting medication reconciliation.

One helpful intervention to consider at the institutional level is recruiting the assistance of a pharmacist-driven or pharmacist-aided medication reconciliation process. In a 2016 meta-analysis published in BMJ Open, pharmacist-led medication reconciliation programs have shown pooled relative risk reductions of 67%, 28% and 19% in ADE-related hospital revisits, ED visits and hospital readmissions, respectively.

Another beneficial intervention to consider at the division or department level is by building and conducting workshop sessions on medication reconciliation. Workshops help with raising awareness of the scope of the problem, reviewing standard workflow and generating novel in-house ideas and solutions that are institution specific and relevant. At larger academic institutions, regularly scheduled workshops held during peak new provider onboarding season can be particularly helpful with practice standardization.

Marissa Mangold

In conclusion, it is difficult to overstate the importance and the intricacies associated with the practice of medication reconciliation. ADEs occur at an alarming rate, and a subset of these have the potential to result in severe discomfort or clinical deterioration. There are many sources of information from which medication history can be gathered, and therein lies the challenge of consolidating that information and distilling it down to an accurate list of medications at each transition of care. Various barriers hinder the precision and timeliness of this process, so it is anything but straightforward. The best practice of medication reconciliation, if such proclamation can be made regarding this highly complex process, should make use of generally accepted practice-improving tips, as well as incorporating pharmacist-assisted interventions and peer-to-peer workshops.

References:

• Abdulghani KH, et al. Int J Clin Pharm. 2018;doi:10.1007/s11096-017-0568-6.
• Agency for Healthcare Research and Quality. Medications at transitions and clinical handoffs (MATCH) toolkit for medical reconciliation. https://www.ahrq.gov/patient-safety/settings/hospital/match/index.html. Accessed Jan. 23, 2024.
• Almanasreh E, et al. Br J Clin Pharmacol. 2016;doi: 10.1111/bcp.13017.
• Boockvar KS, et al. J Hosp Med. 2011;doi:10.1002/jhm.891.
• Kulkarni SA, Wachter RM. Annu Rev Med. 2023;doi:10.1146/annurev-med-051022-043301.
• Lester PE, et al. MedEdPORTAL. 2019;doi:10.15766/mep_2374-8265.10852.
• Mekonnen AB, et al. BMJ Open. 2016;10.1136/bmjopen-2015-010003.
• Pippins JR, et al. J Gen Intern Med. 2008;doi:10.1007/s11606-008-0687-9.
• Tam VC, et al. CMAJ. 2005;doi:10.1503/cmaj.045311.