The Why, Who, and How of Medication Reconciliation
November 2008 - Vol. 5 No. 11


The vast majority of available literature attempts to convince the reader that medication reconciliation is indeed important to patient safety and the lack of an accurate process leads to medication errors, which is undeniably true. This is well known, thanks in part to the Institute of Medicine’s recent report and, of course, the Joint Commission’s National Patient Safety Goal. However, those involved in designing a program often fail to convey to the staff performing the reconciliation the “why” behind it. Without helping people understand how this will impact the care of their patients, there is little buy-in, which invariably results in failure or certainly mediocrity — both of which are unacceptable. A culture shift must occur that places the emphasis on safety and accuracy, and that culture shift cannot occur without strong leadership.

One missing step that can certainly lead to failure is that of an inappropriate invitation list when designing the medication reconciliation process. Who you invite to the table is critical. Several initial failures have resulted from not inviting physicians to the kick-off meetings, where decisions about the process are made. Clearly, given physicians’ habits, if the process is not simple and convenient, they are not going to use it. And if they are not going to use a process, it will fail. The same applies to nurses; they will find a way around a process that is not simple and convenient. Ensure the group working on designing a process includes representatives from pharmacy, nursing (critical care and medical units, as well as ancillary units/departments, such as radiology, surgery, and emergency services), physician groups, information systems, education department, public relations, administration, retail pharmacy, and patients, if your institution has reached that level of comfort with disclosing your opportunities for improvement (otherwise known as imperfections). Representatives are needed from varying nursing units because their reconciliation issues will differ, especially with transfers and discharges.

Your information systems department can play an important role in streamlining the process through automation, and the public relations and education departments can be a great source for communicating change within your institution and to the public. Administrative representation is necessary to facilitate change on a broad level, and their engagement is critical. Developing partnerships with local retail pharmacies can help immensely with closing the loop between discharge from the hospital and an accurate medication list. Patients offer insight and feedback that no one working in health care could ever match. Since this is for their benefit, it makes sense to design a system that will work for them.

Probably the biggest “who” issue to consider is which discipline will be responsible for the initial reconciliation of home meds. A common pitfall is the lack of training for those individuals responsible. Often the nurse assigned to the care of the patient collects this list from the patient or their family and may even collect their prescription bottles if they happen to bring them into the hospital. Perhaps the best approach is to offer specific training to a select group (consider a mix of nurses, pharmacists, pharmacy technicians, pharmacy residents, and students) and limit the task to this group. This creates a sense of ownership and responsibility, which will lead to greater accuracy. The number of employees needed to accomplish accurate medication reconciliation needs to be evaluated based on census and acuity. First, calculate the time it takes to perform an average reconciliation. In my experience, it takes from four to seven minutes, but can take longer if you are dealing with a complicated patient or if you have to call retail pharmacies, physician offices, or other outside sources of information. Multiply that time by your average number of admissions to get a good idea of how many FTEs you will need for your medication reconciliation program. I recommend sharing the medication reconciliation responsibility across disciplines, so that it does not drain one resource completely.


The key to a successful program lies in the development of a process that results in useful, reliable, and timely information for the physician to use when making decisions regarding a patient’s medication regimen. One of the most successful first steps is the creation of an admission medication assessment form that serves as an order form for the physician. (See Figure1.) This eliminates the need for transcription, which, in turn, reduces the chance for error. Automating this step further promotes safety by eliminating illegibility as an issue, and makes the transfer and discharge reconciliations much easier and more accurate, since this information follows the patient through their entire hospital stay. An inpatient drug list can be pulled from your pharmacy information system and the patient’s home medication list can be pulled from the information electronically entered into the hospital’s information system upon admission. This information is then used to automatically populate a form for your physicians’ use during transfer and discharge. Some software vendors offer automated form generation as a standard feature, or your hospital’s IT department can create it in-house. Do not be afraid to modify this form 25 times if that is what it takes to make it work for the staff. And certainly do not be afraid to borrow someone else’s form. (See Figure 2.) 

Include tactics in your specific reconciliation training for how to best interview patients or their families. Use open-ended questions, such as “Which prescription medications do you take?” versus the closed approach of “Do you take any prescription medications?” Follow up with “How do you take that medication?” versus simply noting what the bottle says or the way they are supposed to take it. Remember that the most reliable reconciliation information will come from the patient. With a little training and skill, interviewers will discover that Mrs. Smith really only takes that blood pressure medicine once a day, instead of the prescribed twice daily dose, because it costs too much. The physician will need to make decisions regarding this patient’s care based upon the information collected and the patient’s physiological presentation. It is vital for the physician to know how the patient is really taking her meds. Some may say there are no poor historians, only poor history takers, but in the case of an unconscious patient, the history taker is off the hook. In these situations, use available resources such as physicians’ office records, retail pharmacies, and family members.

It is easy to forget the variety of agents that qualify as medications, and each needs to be addressed when collecting the list. Be sure to ask about prescription drugs, over-the-counter drugs and remedies, herbals, inhalants, samples, nutritionals, topicals, and even injectable drugs. Be sure to ask which retail pharmacy the patient usually uses, in case you need to call and verify any information. Keep in mind, however, that patients are not loyal to their pharmacist anymore; they are loyal to price. Patients will often shop for the best prices and use multiple pharmacies.

When addressing issues with transfer reconciliation, the best answer is to automate, automate, automate. If the initial home medication list is also automated and, therefore, follows the patient throughout their hospitalization, ensure this list is made conveniently available to the physician during transfers. The best way to ensure compliance with transfer reconciliation is to automatically generate an active medication list from the pharmacy profile system that can be used as an order form for the physician. Some pharmacy systems offer this in their software packages, but many hospital information system departments have also developed their own. This order form should have a space for the physician to quickly and easily decide what to continue, discontinue, or change in the patient’s regimen with a mere check in a box. (See Figure 2.) Ensure the policy enforces the requirement for transfer reconciliation to occur for all patients changing level of care and those visiting the OR and the cath lab. Do not accept blanket orders to “continue all previous meds”.

The “how” for discharge can very closely follow the process with transfer reconciliation. Automation is key. Provide the physician with either a computer-based or computer-generated discharge medication order form, listing both current in-hospital medications and those the patient was taking at home. This way, the physician will be able to compare the lists and make informed decisions about the best regimen for the patient. Again, it cannot be stressed enough that this needs to be very available and very easy.


Medication reconciliation is a vital step in a medication safety program. Focusing on the why, who, and how are vital to organizing a team and creating and implementing a successful program. Avoid the pitfalls that result in failure and be willing to change and be flexible along the way, and a successful program will be the end result. 

In September 2007, Natasha Nicol, PharmD, took on her current post as the medication safety director for Cardinal Health. Prior to assuming this role, she was the director of pharmacy for McLeod Regional Medical Center in Florence, South Carolina, for six years. Nicol earned her doctorate of pharmacy degree, with honors, from the University of Maryland.


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