SCP: Medication Reconciliation 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 (see below for more information).

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.

The following information contains additional (optional) guidance for HCOs implementing “Medication Reconciliation”:

·         The literature shows that most successful Medication Reconciliation interventions rely heavily on pharmacists (Mueller et al 2012, Kwan et al 2013). A multidisciplinary team approach including physicians and nurses is needed to ensure Medication Reconciliation is completed successfully (ISMP Canada 2011).

·         Patient involvement, including patient interviews, is important in the Medication Reconciliation process. The patient is the only constant participant across the system and is critical to the success of this major system change (ISMP Canada 2011). Medication counseling to patients and follow-up is recommended (Mueller et al 2012).

·         In the hospital setting Medication Reconciliation can be applied for patients in any wards (e.g. medical wards, surgery wards, pediatric wards, critical care units etc.) (Kwan et al 2013). Focusing on high risk patients may assist in directing resources efficiently. Examples for selection criteria for high risk patients are advanced age, presence of chronic illnesses, or use of multiple medications. However, in the literature there are conflicting results as to whether focusing on high risk patients improves the effect of Medication Reconciliation (Kwan et al 2013, Mueller et al 2012).

·         Guidance suggests Medication Reconciliation should occur within 24 hours of hospital admission (ISMP Canada 2011).

·         Communication with postdischarge providers regarding the discharge medication regimen is recommended, including how and why the regimen differs from before admission (Mueller et al 2012).

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).

The website of ISMP Canada provides guidance and tools for implementing Medication Reconciliation in further settings, e.g. long-term care and home care  (March 13 2013)].