Be Ready For Medication Reconciliation

By  //  January 26, 2014

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BREVARD COUNTY • MELBOURNE, FLORIDA — Medication reconciliation (MR) is an important hospital process that clarifies the medications that a patient is taking during and then subsequently after they go home.

MR is inherently an easy concept, yet, for a variety of reasons, hospitals nationwide struggle performing the process effectively.


The steps are as follows:

1. Obtain an accurate up-to-date list of medications that the patient is currently taking at the time of admission, including all prescription, over-the-counter, vitamins and herbal medications.

2. Receive all medication orders prescribed by the admitting doctor.

3. Compare those two medication lists.

Obtaining an accurate and complete list of patient medications is the crucial first step in the complex process of medication reconciliation.

4. Clinically interpret and make decisions based on the medications listed.

5. Communicate that final, therapeutically optimal list to the appropriate people, i.e. the patient, caregivers, health-care team.

6. Update medication information throughout the hospital course.

7. Ensure patient, at-home caregivers and doctors receive accurate discharge med list.

Sounds simple, right?  In theory, yes, however, in practice medication reconciliation is not so simple.


Last year much of my research was on high-risk medications and associated complications that led to adverse drug events, which subsequently put many patients back into our hospitals.

A breakdown at the time of hospital discharge in the knowledge and understanding of what medications a patient should be taking and how to take them results in a high rate of preventable hospital readmissions.

The Centers for Medicare and Medicaid Services (CMS) have designated three conditions – acute myocardial infarction or a heart attack, heart failure and pneumonia – that must be monitored for outcomes, one of which is the percentage of patients who are readmitted to the hospital within 30 days after their discharge from the initial hospital stay for that condition.

CMS hospital reimbursement payments are then adjusted down for hospitals with a higher than acceptable 30-day readmission rate.

Using my training as a medication safety pharmacist I performed a meta-analysis to determine what the literature commonly identified as the cause of these readmissions and what their proposed solution was in decreasing the occurrence of these preventable events based on published studies.

The majority of this peer-reviewed research identified an incomplete or inaccurate MR as the culprit for many of these patients returning to the hospital. An accurate MR at the time of admission, transfer and discharge assists in discrepancy recognition, including identification of duplicate therapy, omitted medications, interacting medications and/or disease states, and incorrect dosing or timing, thereby decreasing adverse drug events that could potentiate a readmission.


I shared my meta-analysis results and analysis with several non-medical friends and family members.  After describing the process of medication reconciliation to them, they looked at me puzzled as to why our hospitals were having such a difficult time.

Realizing that the layperson has no underlying knowledge of the complexity of hospital/medical operations I had my “AHA” moment and, in trying to explain the multifactorial nature of MR, described a hypothetical patient as such:

1.  A patient comes to the hospital, like many patients, with no medication list in hand and a very poor recall and understanding of what medications they take on a day-to-day basis.

2.  The hospital associate assigned to perform the medication reconciliation then asks which pharmacy they use for prescription medications, hoping that the information he/she needs might dwell in that pharmacy’s system.

Many patients obtain multiple medications from a variety of sources, which frequently makes medication reconciliation a complex and challenging process.

3.  If the associate responsible for compiling this very important list is lucky, the patient does not corner-pharmacy shop.  Ideally, the patient is loyal to one pharmacy, however, if they have medications at Pharmacies X,Y and Z (because prescription A is cheaper at pharmacy X and they received $25 to transfer prescription B to pharmacy Y, and they think the pharmacist at pharmacy Z is extra nice, etc.) it requires a time-consuming quest for accurate information involving calls to pharmacies, physician offices and relatives.

4.  To add an extra layer, this patient could be like many patients that are admitted and have several physicians overseeing their care: their primary care physician, endocrinologist, cardiologist, pulmonologist, etc.

After verbalizing this to my loved ones, leaving them confused and me frustrated at how complex, uncoordinated, not to mention unfair the process can be for one patient, it was quite apparent why this is such a challenging process for hospitals.


Resources and programs focused on improving information exchange between caregivers, patients and their families is key to refining and enhancing the MR process. As hospital cultures embed the principle that the patient is the most valuable person on the health-care team, and “patient-centered” care becomes the foundation of that culture, patients and their advocates are empowered to become more active and participatory in, as well as responsible and accountable for their health outcomes.


One of the biggest contributions a patient can make in helping the health-care team provide for them in the most safe and effective way is to be a good historian, know what medications they take, and have a plan how to communicate that information to other caregivers.

trying to use just one pharmacy for purchase of prescription medications creates a reliable electronic history that can be invaluable to MR.
Trying to use just one pharmacy for purchase of prescription medications creates a reliable electronic history that can be invaluable to successful medication reconciliation, and also helps develop a good working relationship with your pharmacist.

The important pieces of information that the patient should provide when the medication list for MR is being compiled are the name, dose, frequency and route of each medication.

This can be on a paper list the patient keeps with them and updates to be current or it can be a list kept on a smart phone if the patient is more electronically savvy.

Also, trying to use just one pharmacy for purchase of prescription medications creates a reliable electronic history that can be invaluable to MR, and also helps develop a good working relationship with your pharmacist. Help us help you have a safe, uneventful hospitalization and avoid a preventable return to the hospital.


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Dr. Jaclyn Jeffries

Jaclyn Jeffries, PharmD graduated from Purdue University College of Pharmacy with her Doctor of Pharmacy degree in 2012, and then obtained a certificate of residency in medication safety from the Purdue University College of Pharmacy Center for Medication Safety Advancement in 2013.  Dr. Jeffries moved from Indiana to Florida July 2013 to be the Pharmacy Safety Officer for Health First.  Her interests include transitions of care, quality improvement initiatives and medication safety.