Medication Reconciliation

Aim

Medication reconciliation is the formal process of checking a patients’ medication. Medication reconciliation should be performed directly after a transfer from one care setting to another care setting or the patients’ home in order to ensure continuity of care, thereby reducing the risk of medication errors and drug-related problems. In addition, the preparation of a medication review should also include medication reconciliation. The focus of medication reconciliation is primarily to obtain completeness of information and secondly to detect discrepancies between records.

Stepwise process

Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it is in line with all the other medication information). Input for the reconciliation preferably should be the patients’ medication record (prescriptions and non-prescription drugs and their use, additional information), medical record(s) (prescribed medication and its use, additional information) and information provided by the patient and/or his or her carers (drugs actually used by the patient and their use, complaints about the medication used, stocks held by the patient). Once all relevant information has been collected, the full list has been created and obvious errors (e.g. double medication) have been eliminated, an in-depth check on the appropriateness of the medication should be performed. This process is known as medication review (see table). Obviously, a medication review should always include a medication reconciliation.

Reconciliation vs review

ADEs = adverse drug events

Transitional care

Transitional care of which medication reconciliation is a part, refers to the coordination and continuity of health care during a move of a patient from (the responsibility) of one health care setting to either another or to home. These so-called care transitions, between health care practitioners and/or settings are important moments, as the patient’s condition and care needs change during the course of a chronic or acute illness and their treatment. Key factors identified to warrant a high quality of transitional care include the existence of standard procedures clearly defining tasks and responsibilities, clear and open lines of communication for the exchange of information between health care practitioners, an adequately executed process of medication reconciliation and a clear willingness of health care practitioners to act in a competent manner and adhere to procedures (display of professionalism).

Transition of care and patient safety

Transition of care increases the risk of medication errors. Poor communication, in advert information loss and inadequate professional behaviour are the main causes. Particularly during a stay in the hospital or in a long term care facility of patients with a number of chronic disease several changes in the medication regimen may be introduced, including changes in the dose or use as well as the discontinuation or initiation of therapy. Although the majority of changes will have been made intentionally, unintentional changes may also have occurred. After discharge from the hospital or care facility, it is not always clear to the patient and the next coordinating healthcare provider which medicines and which doses should be used at home. In addition, clear instructions how to use the medication may also not have been given. All in all, the transition may result in the erroneous use of (inadequate) medication. Medication errors and drug-related problems may result in harm to the patient, such as adverse events and re-hospitalizations.

Medication reconciliation interventions

Pharmacists and pharmacy technicians are often involved in medication reconciliation interventions. Pharmacist-led medication reconciliation programmes may reduce the occurrence of adverse drug events, emergency department visits and hospital readmissions. Medication reconciliation should become a common practice and must be integrated into daily practice as part of daily health care provision. Guidelines for the transfer of information on patients medicines, allergies, contraindications and laboratory information e.g. renal function, electrolytes are available in a number of countries. Health care providers should comply to these guidelines, establish and maintain lines of communication and feel responsible for adequate transfer of information when a patient is admitted to or discharged from the hospital or transferred to another care unit.

Guidelines, protocols and toolkits

In some countries, guidelines, protocols and toolkits have been developed to facilitate the transfer of the information from hospital to the primary care professionals, including the pharmacist. In 2014, the WHO produced the third version of a Medication reconciliation SOP (Standard Operating Procedure), as part of the High5S Action. It covers implementing medication reconciliation on admission, at internal transfer and on discharge from hospital. Other developments have taken place in the USA, where the Institute for Healthcare Improvement published a number of guiding documents for medication reconciliation process and policy, also around 2015. Also in Canada, the Institute for Safe Medication Practices provides recommendation for medication reconciliation and a variety of toolkits and learnings supporting implementation. The Australian Commission on Safety and Quality in Health Care provides a guideline including plans for medication management. In the UK, the website of the National Institute for Health Care Excellence (NICE) provides a guideline on medication reconciliation, practical forms and tools as well as an implementation support programme. The Dutch Multidisciplinary guideline is published on a website medicatieoverdracht.nl (in Dutch), created in 2013, includes a check-list and describes which information should be transferred at discharge. In addition to the chronic medication, medication that has recently been stopped, and medication that should only be continued for a limited time should also be listed.

Key literature

Durán-García E, Fernandez-Llamazares CM, Calleja-Hernández MA. Medication reconciliation: passing phase or real need? Int J Clin Pharm 2012; 34: 797-802.

Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397-403.

Claeys C, Foulon V, Winter, de S, Spinewine A. Initiatives promoting seamless care in medication management: an international review of the grey literature. Int J C Pharm 2013; 35: 1040-1052.

Rose AJ, Fischer SH, Paasche-Orlow MK. Beyond medication reconconciliation. JAMA 2017; 317: 2057-2059.

Websites

http://www.ihi.org/Topics/ADEsMedicationReconciliation

www.ismp-canada.org/medrec/

www.safetyandquality.gov.au/our-work/medication-safety/medication-reconciliation

www.nice.org.uk/guidance/ng5/chapter/1-Recommendations#medicines-reconciliation

www.medicatieoverdracht.nl