Medical Reconciliation

What is medication reconciliation?

A formal process where healthcare professionals partner with patients to ensure accurate and complete medication information transfer at every interface of care

What is the Best Possible Medication History (BPMH)?

The most accurate list of all medications a patient is currently taking, including OTCs, prescriptions, recreational drugs, PRNs, and all dosage forms

Why does medication reconciliation improve patient safety?

It reduces medication errors, prevents ADEs, and ensures accurate communication during transitions of care

How common are medication history errors?

Up to 2/3 of medication histories contain at least one error

What percentage of hospitalized patients experience an ADE?

Nearly 10%, and 40% of these are preventable

What is the main root cause of ADEs?

Poor communication among healthcare teams

When should medication reconciliation occur?

At every transition of care: admission, unit transfer, and discharge

When should medication reconciliation be completed upon admission?

Within 24 hours, or ahead of planned surgeries

Why is medication reconciliation important during unit transfers?

It communicates medication changes, ensures continuity, and allows the new team to understand the treatment plan

When should medication reconciliation occur at discharge?

On the day of discharge and within 14 days

Where else is medication reconciliation routinely performed?

• Primary care appointments

• pharmacies

• long-term care facilities

• nursing homes

• rehabilitation centers

Which patients should be prioritized for medication reconciliation?

Patients at high risk of discrepancies or readmission

What is the 8P Screening Tool used for?

Identifying patients at higher risk of readmission

What defines polypharmacy risk?

Taking 10 or more routine medications

Which psychological factor increases risk?

Positive depression screen or prior depression history

Which principal diagnoses increase risk?

Cancer, stroke, diabetes, COPD, and heart failure

What physical limitations increase risk?

Frailty, malnutrition, deconditioning

How does health literacy impact risk?

Low health literacy or inability to perform teach-back increases risk

How does patient support influence risk?

Lack of social support or primary care increases risk

What prior hospitalization factor increases risk?

Any non-elective hospitalization in the last 6 months

What is the palliative care screening question?

“Would you be surprised if this patient died in the next year?”

Who is considered a high-risk discharge patient?

Those with:

• 8+ discharge meds

• ≥3-day hospital stay

• age ≥80

• females

What are common sources for obtaining a BPMH?

• Patient interview

• outpatient EHR medication list

• pharmacy dispensing records

• pharmacist interview

Why is the patient interview important?

Provides the most accurate medication list when the patient is reliable

Why is the outpatient EHR list useful?

Confirms allergies, reactions, discontinued meds, and historical medication data

What do pharmacy dispensing records help identify?

Fills from other health systems, fill dates, and stored prescriptions

Why is the pharmacist interview crucial?

Identifies discrepancies, adherence barriers, and clarifies patient questions

What are intentional medication discrepancies?

Medications held, changed, or stopped with proper provider documentation

What are undocumented intentional discrepancies?

Purposeful medication changes by a provider without documentation

What are unintentional discrepancies?

• The most dangerous error

• Omission or commission medication errors without clinical justification

What is an omission error?

A home medication being left off the medication list without reason

What is a commission error?

A medication ordered that the patient does not take, or at incorrect dose or frequency

Which drug classes are most commonly associated with medication reconciliation errors?

• Cardiovascular agents

• antidepressants

• GI agents

• neurological agents

• anti-diabetics

Which classes have the highest proportion of medication errors?

• Ophthalmic

• GI

• neurological

• antivirals

• antidepressants