919 / Medication Reconciliation for Implementation in PaSQ

Type of Patient Safety Practice Not Implemented
Clinical Practice (CP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Medication / IV Fluids
Handover situations / Transfer of patients
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
The aim of this Safe Clinical Practice (SCP) is to identify and correct medication errors (unintentional medication discrepancies) across transitions of care.

Transitions in care such as admission to and discharge from the hospital put patients at risk for errors due to poor communication and inadvertent information loss. Up to 67% of patients admitted to the hospital have unintended medication discrepancies, and these discrepancies remain common at discharge (Kwan et al 2013). Almost one-third of medication discrepancies occurring at hospital admission or discharge have the potential to cause patient harm (i.e., potential adverse drug events) (Mueller et al 2012). Adverse drug events associated with medication discrepancies can prolong hospital stays and, in the postdischarge period, may lead to emergency department visits, hospital readmissions, and use of other health care resources (Mueller et al 2012).

The systematic review by Mueller et al 2012 included 26 controlled studies and reasoned that Medication Reconciliation consistently reduced medication discrepancies, potential adverse drug events (i.e., clinically significant discrepancies) and adverse drug events. The systematic review by Kwan et al 2013 included eighteen studies evaluating 20 interventions.The authors come to the conclusion that hospital-based Medication Reconciliation at care transitions frequently identifies unintended discrepancies; however few of these discrepancies seem to have a clinical significance.


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. Available from: http://annals.org/article.aspx?articleid=1656444 (Accessed March 14th 2013)

Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-Based Medication Reconciliation Practices. A Systematic Review. Arch Intern Med. 2012;172(14):1057-69

Description of the Patient Safety Practice
Short description of the SCP and information on implementation:

Medication Reconciliation is the process of identifying the most accurate list of all medications a patient is taking and using this list to provide correct medications for patients within the health care system (IHI 2011).

The majority of the available literature on Medication Reconciliation focuses on hospital-based transitions in care (Kwan et al 2013). For this reason, the below information is most applicable to hospital care. However, Medication Reconciliation can also be implemented in facilities in other settings i.e. primary care, long-term care and home care.

Health care organisations (HCOs) which will implement this SCP within Work Package 5 of the PaSQ Project are expected to introduce the following three-step Medication Reconciliation process (ISMP Canada 2011):

1. Create a complete and accurate Best Possible Medication History (BPMH) of all the patient’s prescribed and nonprescribed medications including name, dosage, route and frequency. More comprehensive than a routine primary medication history, the BPMH involves two steps:

I. a systematic process of interviewing the patient/family and

II. verification of this information with at least one other reliable source of information (for example, patient medication lists, a community pharmacy, a primary care physician, a government medication database, medication vials)

2. Reconcile medications: Use the BPMH to create admission orders or compare the BPMH against admission medication orders, transfer medication orders, or discharge medication orders; identify and resolve all differences or discrepancies; and

3. Document and communicate any resulting changes in medication orders to the patient, family/caregiver and to the next provider of care.

Little guidance exists for Medication Reconciliation in primary care. According to a systematic review, few studies have examined systematic Medication Reconciliation in the primary care setting. The following intervention was described in the two studies conducted in the ambulatory setting which were included in this review: All clinic team members (including receptionists, nurses and physicians) performed Medication Reconciliation at each patient visit. Patients were asked to bring an updated list of their drugs or their medication bottles to clinic appointments. Nurses and physicians then reconciled the patient medication list with the electronic medical record (Bayoumi et al 2009).

Stepwise approach to implementation and evaluation of improvements:

The following outlines the key steps for getting started on the implementation of Medication Reconciliation (modified from the „Medication Reconciliation in Acute Care Getting Started Kit“, ISMP Canada 2011). More detailed information can be found within the tools included in this tool box (e.g. Getting Started Kits of ISMP Canada).

1. Secure senior leadership commitment

Implementing a successful Medication Reconciliation process requires clear commitment and direction from the highest level of the organisation.

2. Form a team

Teamwork is an integral part of the Medication Reconciliation process. Medication Reconciliation is not owned by one discipline. Clinical champions can contribute significantly to successful implementation.

3. Define the problem

•    Set aims (goals and objectives)
•    Collect baseline data

4. Start with small projects and build expertise in reconciling medications

Initially implement a Medication Reconciliation process on a smaller scale with selected groups of patients, on selected units or during a specific point in the continuum of care to develop forms and tools that work in your organisation and to gain expertise in the Medication Reconciliation process.

Although Medication Reconciliation can occur at any of the transition points in care (e.g., admission, transfer, discharge), it is suggested that one starts at the admission process. If Medication Reconciliation is not done right at admission, the process could be continued using inaccurate information. As patients may be admitted to the hospital from a number of points, select one area (e.g. preoperative screening or the emergency department).

5. Evaluate improvements being made – collect data

In order to determine if the implementation has been successful, measurements should be made on an ongoing basis (e.g. monthly). Tracking a few key measures over time is the single most powerful tool a team can use and will help it to see the effects of the changes it is making.

6. Spread

As experience develops and measurement of the success of your Medication Reconciliation process reflects sustained improvement the process can be implemented for more patients in more areas. Evaluate at each new step before adding more units to the process. Organise information and communication activities around the initiative at the different stages of implementation (e.g. for the staff involved).

For further information and references, please see “Annex_SCP_MedRec_Description_130416”.

Attachment of relevant written information and/or photos, as appropriate
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Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Level of implementation of reported practice
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Specific and measurable outcome for the reported practice were defined
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A baseline measurement before implementation of the reported practice was obtained
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A measurement after full implementation of the reported practice was obtained
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Evaluation of a “positive” effect of the reported practice on Patient Safety
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Type of before-and after evaluation
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Enclosure of a reference or attachment in case of published evaluation’s results
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Health care context where the Patient Safety Practices was implemented
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
Primary care
Successful implementation’s level  of this Patient Safety Practice across settings
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Involved health care staff
Clinical manager
Quality manager
Risk manager
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
Point of time in which service user or their reprasentatives’ involvement takes place
During the implementation of the Patient Safety Practices
During the application of the Patient Safety Practice
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Short description of the service users’ level of involvement
Collaboration, such as co-designing a Patient Safety Practice or active partnership in implementation
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible
WP5 Tool Box Medication Reconciliation:
Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Not sufficient human resources available
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
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Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Description of used incentives, if any.
There are some incentives for the countries and for the Healthcare Organisations (HCOs) to take part in implementing Medication Reconciliation in the course of Work Package 5 of the Joint Action on PaSQ:
– Taking part in a European Union Project
– Exchange of knowledge and experiences with other European countries (network)
– Most of the countries receive budget for implementation
– The names of the HCOs are published on the PaSQ website
– Marketing aspects
– Pioneering role
– A tool box on Medication Reconciliation has been developed for support
– Possibility to participate in webinars on Medication Reconciliation
– Opportunity to consult with the National Contact Point of the corresponding country
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Total number of person days required to implement this Patient Safety Practice
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Total number of person days required for training as preparation for implementation of this Patient Safety Practice
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Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
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Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
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