LR14 / Clinical risk management (CRM) practice on Medication reconciliation

Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice


System resilience
Patient safety theme the SCP/clinical risk management practice is aimed at
Medication reconciliation
Objective of the CRM practice
Medication errors occur frequently at points in the transition of care[7-9], incomplete and inappropriate medication reconciliation at hospital discharge (partly from inadequate medication reconciliation at admission), insufficient patient information and insufficient communication to the next health care provider are key factors for medication errors[10]. Previous interventions aimed at medication reconciliation partly used pharmacists thereby making it expensive[1-6,11-15], used medication records without actively involving patients[1,2,12,14].
Short description of the CRM practice, including any references for further information
The Continuity of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare (COACH) programme is designed to improve continuity of care by combining interventions (including medical reconciliation at discharge, patient counselling at dischrage and communication of medication information to the next healthcare provider) and using pharmaceutical consultants to perform the intervention[16].
Innovator of the SCP, country of origin
Experimental study performed at the St Lucas Andreas Hospital, the Netherlands
Involved health care staff
Pharmaceutical consultants (pharmacy technicians who acquired an additional three-year bachelor program focused on pharmaceutical patient care) and clinical pharmacists.
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
General teaching hospital/Internal medicine[16]
Summary of evidence for effectiveness, including references
Discharge medication related interventions reduce adverse events, reduce readmission rate and improve adherence[1-6].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
Summary of available information on feasibility, including references
Study was conducted in one centre, therefore limiting generalisability of the result.
Existing implementation tools, including references
Potential for/description of patient involvement in the CRM practice, including references
Patients are actively involved in the COACH, they fill out a questionnaire about adherence to drug treatment( MARS; Medication Adherence Rating Scale)
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Al-Rashed SA, Wright DJ, Roebuck N, Sunter W, Chrystyn H (2002) The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. Br J Clin Pharmacol 54:657-664

[2] Boockvar KS, Carlson LH, Giambanco V, Fridman B, Siu A (2006) Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother 4:236-243

[3] Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA (2004) Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother 2:257-264

[4] Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, Kachalia A, Horng M, Roy CL, McKean SC, Bates DW (2006) Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 166:565-571

[5] Varkey P, Cunningham J, O’Meara J, Bonacci R, Desai N, Sheeler R (2007) Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm 64:850-854

[6] Lopez CC, Falces SC, Cubi QD, Arnau BA, Ylla BM, Muro PN, Homs PE (2006) Randomized clinical trial of a postdischarge pharmaceutical care program vs regular follow-up in patients with heart failure. Farm Hosp 30:328-342

[7] Coleman EA, Smith JD, Raha D, Min SJ (2005) Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 165:1842-1847

[8] Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE (2005) Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 165:424-429

[9] Vira T, Colquhoun M, Etchells E (2006) Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 15:122-126

[10] Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE (2005) Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 173:510-515

[11] Holland R, Lenaghan E, Harvey I, Smith R, Shepstone L, Lipp A, Christou M, Evans D, Hand C (2005) Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ 330:293

[12] Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, Forsythe SR, O’Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L (2009) A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 150:178-187

[13] Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, Cheng D, Masica AL (2009) Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med 4:211-218

[14] Nickerson A, MacKinnon NJ, Roberts N, Saulnier L (2005) Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q 8 Spec No:65-72

[15] Scullin C, Scott MG, Hogg A, McElnay JC (2007) An innovative approach to integrated medicines management. J Eval Clin Pract 13:781-788

[16] Karapinar-Carkit F, Borgsteede SD, Zoer J, Siegert C, van TM, Egberts AC, van den Bemt PM (2010) The effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients. BMC Health Serv Res 10:39

Any additional information on the CRM (e.g. implementation barriers and drivers)