PharmD Info

Medication reconciliation is a complex process that affects all patients as they move through all health care settings. It is a comparison of the patient’s current medication regimen against the physician’s admission, transfer, and/or discharge orders to identify discrepancies.

Any discrepancies noted are discussed with the prescriber, and the order is modified, if necessary. Although this toolkit is based on processes developed in acute-care settings, the core processes, tools, and resources can be adapted for use in non-acute facilities.

Medication reconciliation is a process to decrease medication errors and patient harm in the
following ways:

Obtaining, verifying, and documenting the patient’s current prescription and over-the-counter medications—including vitamins, supplements, eye drops, creams, ointments, and herbals—when he or she is admitted to the hospital or is seen in an outpatient setting.

Considering the patient’s pre-admission/home medication list when ordering medicines
during a hospital encounter and continuing home medications as appropriate, and comparing the patient’s pre-admission/home medication list to ordered medicines and treatment plans to identify unintended discrepancies (i.e., those not explained by the patient’s clinical condition or formulary status).

Verifying the patient’s home medication list and discussing unintended discrepancies with the physician for resolution.

Providing an updated medication list and communicating the importance of managing
medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter.