Medicines reconciliation explained

Medicines reconciliation or medication reconciliation is the process of ensuring that a hospital patient's medication list is as up-to-date as possible. It is usually undertaken by a pharmacist and may include consulting several sources such as the patient, their relatives or caregivers, or their primary care physician.

In the United Kingdom, guidelines on medicines reconciliation are provided by the National Institute for Health and Care Excellence (NICE) in collaboration with the National Patient Safety Agency.^[1] In accordance with these, it should be carried out within 24 hours of admission to hospital. From April 2020 it is to be an essential service in the community pharmacy contract in England.^[2]

In the United States, the Joint Commission prioritizes medication reconciliation at hospital admission and during ambulatory care as one of the National Patient Safety Goals.^{[3] [4]}

Importance

Research has shown that, on average, there is around a 20% discrepancy between medications prescribed on admission to hospital and the true medication list for a given patient.^[5] Chronic medications are stopped in about 11% of the patients after elective surgeries^[6] and 33% of the patients after admission to intensive care unit.^[7] The most common omissions are inhalers and analgesia. There are also a small minority of errors in prescribing drugs such as insulin or warfarin, which could have catastrophic consequences including death of the patient. Pharmacist involvement help reasons for drug discontinuation being documented^[8] and adverse drug reactions being reconciled in the prescription charts.^[9] The value of medicines reconciliation is in noticing and correcting these errors before they have a chance to adversely affect the patient concerned. Research shows that the main activity of medicines reconciliation by pharmacists is to identify or assess drug-related problems and discuss them with other professionals. However, the process and the tools used in medicines reconciliation vary greatly. There is a wide variation in how medicines reconciliation is conducted and which methods are utilized in different country and hospitals.^[10]

Notes and References

1. National Patient Safety Agency. NICE NPSA medicines reconciliation adults in hospital. Patient Safety Alert, Reference number 1035. Issue date 1 December 2007. London, UK. http://www.npsa.nhs.uk/corporate/news/guidance-to-improve-medicines-reconciliation/
2. News: Medicines reconciliation to be an essential service from 2020/2021, says NHS England . 22 March 2020 . Pharmaceutical Journal . 28 January 2020.
3. Prey. Jennifer E.. Polubriaginof. Fernanda. Grossman. Lisa V.. Masterson Creber. Ruth. Tsapepas. Demetra. Perotte. Rimma. Qian. Min. Restaino. Susan. Bakken. Suzanne. Hripcsak. George. Efird. Leigh. 2018-11-01. Engaging hospital patients in the medication reconciliation process using tablet computers. Journal of the American Medical Informatics Association. en. 25. 11. 1460–1469. 10.1093/jamia/ocy115. 30189000. 7263785. free.
4. Web site: Hospital 2020 National Patient Safety Goals. 2020-10-29. www.jointcommission.org. en.
5. Urban . R . Armitage . G . Morgan . J . etal . 2014 . Custom and practice: a multi-center study of medicines reconciliation following admission in four acute hospitals in the UK. . Res Social Adm Pharm . 10 . 2. 355–68 . 24529643 . 10.1016/j.sapharm.2013.06.009 .
6. Bell . CM . Bajcar . J . Bierman . AS . Li . P . Mamdani . MM . Urbach . DR . 2006 . Potentially unintended discontinuation of long-term medication use after elective surgical procedures . Arch Intern Med . 166 . 22. 2525–31 . 17159020 . 10.1001/archinte.166.22.2525 . free .
7. Bell. Chaim M.. Rahimi-Darabad. Parisa. Orner. Avi I.. 2006-09-01. Discontinuity of chronic medications in patients discharged from the intensive care unit. Journal of General Internal Medicine. 21. 9. 937–941. 10.1111/j.1525-1497.2006.00499.x. 1525-1497. 1831608. 16918738.
8. Yeung . E . November 11, 2016 . Are we legitimately stopping medications? Use of pharmacist and junior doctor teaching to improve medication reconciliation . Br J Gen Pract .
9. Yeung. Eugene Y. H.. 2015-10-01. Adverse drug reactions: a potential role for pharmacists. The British Journal of General Practice. 65. 639. 511.1–511. 10.3399/bjgp15X686821. 1478-5242. 4582849. 26412813.
10. Gondora . Nyasha . Versteeg . Sarah G. . Carter . Caitlin . Bishop . Lisa D. . Sproule . Beth . Turcotte . Dana . Halpape . Katelyn . Beazely . Michael A. . Dattani . Shelita . Kwong . Mona . Nissen . Lisa . Chang . Feng . May 2022 . The role of pharmacists in opioid stewardship: A scoping review . Research in Social and Administrative Pharmacy . 18 . 5 . 2714–2747 . 10.1016/j.sapharm.2021.06.018 . 1551-7411.