Medication reconciliation is the process of creating the most accurate and complete list possible of a patient’s current medications, while also comparing that list to those in the medication orders or patient record. Medication errors can have dangerous and even fatal results. According to the National Library of Medicine, the average hospitalized patient experiences at least one medication error per day, confirming research findings that medication errors remain the most common patient safety error.

In fact, more than 40 percent of medication errors arise from improper reconciliation in handoffs during the admissions, transfer, and discharge process. Of those errors, 20 percent result in harm. Many of those errors can be prevented with the proper medication reconciliation processes in place.

Medication reconciliation takes the combined effort of all healthcare providers, from doctors prescribing the medication to the pharmacies filling them.

A Pharmacy’s Role in Medication Reconciliation

Due to their distinct knowledge, skills, and abilities, pharmacists are uniquely qualified to lead interdisciplinary efforts in establishing and maintaining an effective medication reconciliation process. Pharmacists can fill key roles in the many vital components of medication reconciliation, such as:

  • Development of policies and procedures
  • Implementation and continuous improvement of the medication reconciliation process
  • Training of others in the core competencies of medication reconciliation
  • Development of information systems to support medication reconciliation
  • Advocation of medication reconciliation programs within the community

Pharmacists indeed share responsibility and accountability with other health-system leaders for the consistent success of medication reconciliation processes across all levels of care. Their responsibilities lie in building a complete list of a patient’s medications, checking them for accuracy, and documenting and reconciling any changes.

According to Pharmacy Times, the goal of medication reconciliation is to identify and resolve discrepancies between the patient’s home medication list with medications ordered by the prescriber at every transition of care. This includes looking for medication omissions, duplications, and documentation errors, while ensuring any changes are clearly communicated among clinicians.

Routine patient management has many benefits, including the prevention of adverse events (AEs) that can impact patient outcomes. Pharmacy involvement is vital in this process when creating medication reconciliation best practices, and should include obtaining full medication histories and completing admission/discharge reconciliation.

Pharmacy Participation: A Key Part of the Process

The key role that pharmacists play in the medication reconciliation process has many benefits for patients and the system as a whole. Indeed, it is a cost-effective approach to optimizing patient care through the prevention of medication errors during transitions, and the facilitation of communications among doctors. It can even give providers more time for other patient care tasks, while reducing readmissions.

Step one is to obtain a thorough, accurate list of the patient’s medications, including OTC, prescription, and complementary or alternative medications. If a patient has been transferred from an outside facility, the list should include medications received there or during the transfer process. The World Health Organization (WHO) says that 67 percent of medication histories hold at least one error, with 27 percent of prescribing errors deriving from inaccurate or incomplete home medication lists.

Accurate patient home medication lists pave the way for more efficient admission and discharge reconciliation processes, while reducing prescribing errors.

Step two is admission reconciliation, which involves the comparison of the home medication list with the orders placed by the prescriber. Pharmacy involvement at this stage in the process has been shown to significantly reduce mean discrepancies per patient, potential AEs, and annual costs.

The final step is discharge reconciliation, which involves a review of the patient’s home medication list, medication admin record, and medical notes for any changes during hospitalization. This produces a discharge medication list. However, studies show that 40 percent of discharge medication lists contain discrepancies, posing a great risk to patients who are returning to the home environment where they will not be monitored.

Best practice should include the involvement of pharmacies within multidisciplinary teams to manage transitions of care. Medication reconciliation processes have been proven to reduce medication errors and support safe medication use. Pharmacists are uniquely poised to create and continually maintain an effective medication reconciliation process in hospitals and across all health systems, and therefore should assume key roles in this endeavor across the continuum of care.

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