Chapter 38. Medication Reconciliation 

Jane H. Barnsteiner 

Background 

According to the Institute of Medicine’s Preventing Medication Errors report,1 the average 

hospitalized patient is subject to at least one medication error per day. This confirms previous 

research findings that medication errors represent the most common patient safety error.2

 More 

than 40 percent of medication errors are believed to result from inadequate reconciliation in 

handoffs during admission, transfer, and discharge of patients.3 Of these errors, about 20 percent 

are believed to result in harm.3, 4 Many of these errors would be averted if medication 

reconciliation processes were in place. 

Medication reconciliation is a formal process for creating the most complete and accurate list 

possible of a patient’s current medications and comparing the list to those in the patient record or 

medication orders. According to the Joint Commission5

 (p. 1),

Medication reconciliation is the process of comparing a patient's medication 

orders to all of the medications that the patient has been taking. This reconciliation 

is done to avoid medication errors such as omissions, duplications, dosing errors, 

or drug interactions. It should be done at every transition of care in which new 

medications are ordered or existing orders are rewritten. Transitions in care 

include changes in setting, service, practitioner, or level of care. This process 

comprises five steps: (1) develop a list of current medications; (2) develop a list of 

medications to be prescribed; (3) compare the medications on the two lists; (4) 

make clinical decisions based on the comparison; and (5) communicate the new 

list to appropriate caregivers and to the patient. 

Recognizing vulnerabilities for medication errors, numerous efforts are underway to 

encourage all health care providers and organizations to perform a medication reconciliation 

process at various patient care transitions. The intent is to avoid errors of omission, duplication, 

incorrect doses or timing, and adverse drug-drug or drug-disease interactions. The Joint 

Commission added medication reconciliation across the care continuum as a National Patient 

Safety Goal in 2005.6

 The Institute for Healthcare Improvement (IHI) has medication 

reconciliation as part of its 100,000 Lives Campaign. This chapter reviews the evidence for 

medication reconciliation and makes recommendations for nursing practice. 

Medication Reconciliation 

A comprehensive list of medications should include all prescription medications, herbals, 

vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast 

agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions 

(hereafter referred to collectively as medications).6

 Over-the-counter drugs and dietary 

supplements are not currently considered by many clinicians to be medications, and thus are 

often not included in the medication record. As interactions can occur between prescribed 

medication, over-the-counter medications, or dietary supplements, all medications and 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

supplements should be part of a patient’s medication history and included in the reconciliation 

process. 

The steps in medication reconciliation are seemingly straightforward.7

 For a newly 

hospitalized patient, the steps include obtaining and verifying the patient’s medication history, 

documenting the patient’s medication history, writing orders for the hospital medication 

regimen, and creating a medication administration record. At discharge, the steps include 

determining the postdischarge medication regimen, developing discharge instructions for the 

patient for home medications, educating the patient, and transmitting the medication list to the 

followup physician. For patients in ambulatory settings, the main steps include documenting a 

complete list of the current medications and then updating the list whenever medications are 

added or changed. 

However, the process of gathering, organizing, and communicating medication information 

across the continuum of care is not straightforward. First, there is tremendous variation in the 

process for gathering a patient’s medication history. Second, there are at least three disciplines 

generally involved in the process—medicine, pharmacy, and nursing—with little agreement on 

each profession’s role and responsibility for the reconciliation process. Third, there is often 

duplication of data gathering with both nurses and physicians taking medication histories, 

documenting them in different places in the chart, and rarely comparing and resolving any 

discrepancies between the two histories. 

Additionally, patient acuity may influence the process of reconciliation. For example, a 

patient admitted for trauma may result in cursory data gathering about the medication history. 

Alternatively, a patient with numerous comorbidities may stimulate gathering a more complete 

list of current medications. In general, there is no standardization of the process of medication 

reconciliation, which results in tremendous variation in the historical information gathered, 

sources of information used, comprehensiveness of medication orders, and how information is 

communicated to various providers across the continuum of care.7

Safety Vulnerabilities Necessitate Medication Reconciliation 

A multitude of factors—such as patients’ lack of knowledge of their medications, physician 

and nurse workflows, and lack of integration of patient health records across the continuum of 

care—all contribute to a lack of a complete medication reconciliation, which in turn creates the 

potential for error. 

Physician and nurse workflows have not traditionally included making a regular inventory of 

all medications a patient is taking (including prescription medications, over-the-counter drugs, 

herbals, and other complementary drugs such as vitamins) or verifying these lists with the 

patient. There has been no standard regarding what constitutes a comprehensive medication 

history or where medication information is kept in the paper or electronic health record. A 

patient’s medication history may be found in the nursing admission database, the medication 

administration record, the physician history, and/or the pharmacy profile. When health care 

information is not integrated across settings, organizations, and among clinicians, it is not easy to 

validate or fill in the gaps from patient-reported information. Patients and family members may 

not be good historians of a medication record, and due to limited access to pharmacy records, 

only an incomplete recording of current medications may be obtained. Lau and colleagues8

compared community pharmacy drug lists with hospitalized patients and found 25 percent of 

prescription drugs in use at home were not recorded on the hospital admission record.

2
Medication Reconciliation

In inpatient facilities, there are several situations where medication reconciliation is needed. 

Generally, patients are admitted to the hospital for a specific procedure, such as surgery, or on an 

urgent basis. When specialty health care providers are focused on the one component of care 

related to the specific encounter and do not take a holistic view to other aspects of the patients’ 

health care needs and practices, it is easy to overlook medications that may cause an adverse 

event when combined with new medications or different dosages. Some of the patient’s daily 

medications may be discontinued during a hospital stay, and when there is a lack of a formal 

reconciliation process on discharge, the need to restart medications upon discharge may be 

overlooked. One example would be discontinuing an anticoagulant during a hospital stay and 

neglecting to restart it upon discharge. Another example is when orders from one unit of care 

(such as intensive care) are discontinued and new orders are written when the patient moves to 

another unit of care (such as a general care unit). The policy necessitating the rewriting of orders 

makes it easy for the prescriber to overlook medications that may need to be reordered when no 

formal medication reconciliation process is in place. These factors combine to create an unsafe 

medication environment in acute care settings. 

Research Evidence 

Medication reconciliation studies have focused on the accuracy of the medication history 

during various transitions: ambulatory to acute care inpatient setting, skilled nursing facility to 

acute care inpatient setting, inpatient acute care setting to skilled nursing facility, inpatient acute 

care setting to discharge, inpatient floor to the intensive care unit (ICU), and ICU to discharge. 

Little research has focused on outcomes related to the prevalence of errors resulting from a lack 

of or an incomplete patient medication list. 

Reconciliation in the Ambulatory Setting 

Medication discrepancies in outpatient records were addressed in three studies. Ernst and 

colleagues9

 found discrepancies in 26.3 percent of charts of patients requesting prescription 

renewal. Of the charts with discrepancies, 59 percent omitted medications from the electronic 

medical record medication list. Miller and colleagues,10 upon examining patient records of an 

ambulatory family practice, found that while 76 percent of patients had prescribed medications, 

87 percent of charts had incomplete or no documentation of those medications. Three years 

following institution of a reconciliation process, which included a form on the chart listing all 

medications ordered for a patient, 82 percent of charts had complete prescription medication 

documentation. Similar findings were noted in a study of cardiology and internal medicine 

practices11 and in a group of patients receiving dialysis.12 Whether patients used the prescribed 

medications as originally prescribed or if their medications were changed by another physician 

was not reported. The reconciliation process requires verification with the patient regarding their 

use of the prescribed medications. 

Reconciliation in Acute Inpatient Settings 

Nine studies examined medication reconciliation in acute inpatient settings. Bayley and 

colleagues7

 identified that the common discrepancies in medication history from ambulatory to 

inpatient care were omitted medication orders, altered doses, or incomplete allergy histories. 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Vira and colleagues13 found a 38 percent discrepancy rate in their study of newly hospitalized 

patients. Gleason and colleagues4

 found more than half of the patients they studied had 

discrepancies in medication histories or admission medication orders. 

Among the most common medication discrepancies between what is in the patient’s history 

and what is ordered upon admission to the hospital was omission of a medication that patients 

reported taking prior to admission.13 These discrepancies result from incomplete documentation 

of the patient’s medication history and a lack of time to search for the information. Nursing staff 

have been noted spending in excess of an hour per patient admission or transfer trying to 

accurately identify medications a patient has been receiving,3 including getting a list of 

preadmission medications from the patient and filling in gaps through the pharmacy and primary 

care physician. 

Chevalier and colleagues14 examined nurses’ perceptions of medication reconciliation 

practices. More than 60 percent of nurses reported that determining the medications a patient was 

taking at home, clarifying medication orders at transfer, and ensuring accurate discharge 

medication orders was a time-consuming process. Time requirements and staffing resources were 

identified as a barrier to completing the process. Although implementing a medication 

reconciliation process will likely consume more health care provider time initially, the process 

may become more efficient once in place. A standardized reconciliation process has been 

reported to reduce work and the rework associated with the management of medication orders. 

Rozich and colleagues15 reported that implementing a systematic approach to reconciling 

medications was found to decrease nursing time at transfer from the coronary care unit by 20 

minutes per patient, and pharmacy time at hospital discharge by more than 40 minutes. Stover 

and Somers16 reported that case managers performing the reconciliation process spent 5 to 10 

minutes per day completing the process with new admissions, and each case manager typically 

reviewed eight new admissions each day. 

One challenge to having an accurate patient medication history is the lack of a standardized 

location in the patient chart where the information may be found. A nurse may need to check the 

nursing admission database, the medication administration record, the physician patient history 

and progress notes, and the pharmacy database. Rozich and Resar15 found that prior to initiation 

of a reconciliation process, details of the current medications in the inpatient chart were 

nonexistent or incorrect 85 percent of the time. Similar findings were found in family practice.17

Nickerson and colleagues18 found that of the medication history discrepancies they identified, 83 

percent had the potential for harm. Others reported that when a medication reconciliation process 

was instituted, it reduced discrepancies from 70 percent to 15 percent.3, 19 Vira and colleagues13

reported that a medication reconciliation process prevented the potential for harm in 75 percent 

of cases. 

Transfers From Inpatient Floor to ICU and Discharge From the ICU 

Two studies by Pronovost and colleagues20, 21 examined medication reconciliation in the 

ICU. Examining discrepancies between medications a patient was receiving in the ICU and the 

discharge orders from the surgical ICU resulted in 94 percent of discharge orders needing to be 

changed. Following implementation of a paper-based medication tracking system, the error rate 

of discharge medication orders was reduced to zero.20 Following implementation of a 

reconciliation process using an electronic form at discharge from a surgical ICU, only 21 percent 

of orders required changing. 

4
Medication Reconciliation

Admissions Between Skilled Nursing Facilities and Hospitals 

A study of medication changes during transfer from nursing home to hospital and hospital to 

nursing home found inaccurate and incomplete reconciliation of medication regimens.22 The 

mean number of medication orders altered per patient on admission to the hospital from a 

nursing home was 3.1, and from the hospital to the nursing home was 1.4. Sixty-five percent of 

the medication changes were discontinuations, 19 percent were dose changes, and 10 percent 

were substitutions for medications with the same indications. The investigators estimated that 20 

percent of the medication changes led to an adverse drug event. 

Inpatient to Discharge 

Four studies looked at the process of discharge from the hospital to home. Bayley and 

colleagues,7 in a qualitative study including nurse, physician, and pharmacist informants, 

reported that reconciliation failures at discharge stemmed from not resuming medications held 

during the hospital stay, and insufficient patient education at discharge. These failures resulted 

from incomplete gathering of the home medication regimen at admission and rushed discharges. 

Moore and colleagues23 found that 42 percent of the patients they studied had one or more 

errors in the discharge medication orders. Most often medications that should have been restarted 

were not. The medications commonly involved were cardiovascular (36.4 percent), 

gastrointestinal (27.3 percent), and pulmonary (13.6 percent). Sullivan and colleagues24 found 

that 59 percent of discrepancies not corrected at discharge could have resulted in patient harm. 

The use of a multipart paper prescription form for discharge medications was found to 

improve accuracy. The form integrates admission medications, in-hospital changes, and 

discharge medications. One part of the form is used as the prescription, the second is placed in 

the chart, the third is given to the patient with instructions for home management, and the fourth 

is sent to the primary care physician. Accuracy of medication prescriptions with the use of a 

multipart form was 82 percent, as compared to 40 percent without the use of an integrated 

process.25 

Medication History Accuracy With Electronic Health Records 

The electronic health record is generally believed to contain more accurate information and 

facilitate easier retrieval of information than paper-based medical records. Studies of medication 

lists in electronic health records have found the data are only as accurate as what has been 

entered. Wagner and Hogan26 found discrepancies between the number of medications patients 

reported taking (5.67) and that listed in the electronic record (4.69). Data entry errors accounted 

for 28 percent of the discrepancies, while 26 percent were related to failure of the clinician to 

enter medication changes into the electronic record. 

DeCarolis and colleagues27 found that a computerized medication profile was inaccurate in 

71 percent of the patients they studied. They demonstrated that implementation of a standardized 

medication reconciliation process reduced the number of patients with unintended discrepancies 

by 43 percent, thereby significantly decreasing the potential for medication errors. However, 

developing and implementing an electronic reconciliation process requires technical support. 

Kramer and colleagues28 reported needing grant funding with hospital matching funds for 

development and programming. Reprogramming is required anytime there are system upgrades. 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Use of a computer order entry system can reduce errors at the time of discharge by 

generating a list of medications used before and during the hospital admission. The medication 

list with instructions can be printed and used for education and review with the patient.7

 The 

utility of such a system depends upon the prior implementation of an admission medication 

reconciliation system. Some electronic discharge medication ordering systems allow for direct 

transfer of the orders to the community pharmacy and to the primary care physician, as well as 

keeping a permanent record on the electronic health record. 

Clearly there is a need for patients, families, health care providers, and pharmacies to have a 

single electronic medication record with everyone working from the same record and all 

medications being reconciled against this record. Electronic systems make it easier to access 

medication histories, but they need to be kept up to date, and information must be correlated with 

patients’ actual medication use. 

Electronic prescribing network systems are being developed that can instantaneously provide 

a patient’s medication history to pharmacists, consumers, and health care providers, while 

protecting patient privacy. Additionally, electronic prescribing allows for key fields such as drug 

name, dose, route, and frequency. Electronic prescribing also allows for decision support such as 

checking for allergies, double prescribing, and counteracting medications. 

Evidence-Based Practice Implications 

There are numerous areas for nurse involvement in the area of medication reconciliation. The 

following are generally consensus recommendations; they have not been subjected to systematic 

study for effectiveness unless noted. 

Define the Steps in the Reconciliation Process 

A first step in having an accurate listing of medications is defining the steps in obtaining a 

complete medication history. IHI suggests three steps to the process: (1) verify by collecting the 

list of medications, vitamins, nutritional supplements, over-the-counter drugs, and vaccines; (2) 

clarify that the medications and dosages are appropriate; and (3) reconcile and document any 

changes.29 Each health care setting needs to develop standards for who is responsible and how 

the process will be completed. Whittington and Cohen reported that the accuracy of medication 

lists went from 45 percent to 95 percent with the implementation of reconciliation standards.30 

Clearly Identify Responsibilities for the Process 

Health care professionals need to clearly identify team roles and responsibilities for 

medication reconciliation. This needs to include evaluating existing processes; identifying a 

standard location in the patient chart where the medication history is kept; and determining who 

will put the medication history onto the agreed upon place in the chart, the time frame for 

resolving variances, and how to document medication changes.31 These processes would 

eliminate the duplication of history taking and documentation that currently exists in many 

settings. 

6
Medication Reconciliation

Consider Use of a Standardized Form 

Many settings have found the use of a standardized medication form facilitates an accurate 

list that is accessible and visible.32 Numerous examples are available on the IHI and Joint 

Commission Web sites. 

Have an Explicit Time Frame for Completion 

Many organizations have a process in place that calls for reviewing the patients’ medication 

list at every primary care visit and within 24 hours of an inpatient admission. High-risk 

medications such as antihypertensives, antiseizures, and antibiotics may need to be reconciled 

sooner, for example, within 4 hours of admission. 

Design Education Programs for Health Care Professionals 

Medication reconciliation is a complex process. Education programs need to include the 

research about medication reconciliation and the steps being put into place to make a safer 

system for patients. 

Design and Implement a Monitoring Process 

Implement a reconciliation review of open and/or closed patient records. Assess adherence to 

the process and identify the potential for and any actual harm associated with unreconciled 

medications. Auditing tools such as the Improvement Tracker on the IHI Web site may assist 

health care settings in tracking their findings over time. Share results with providers so they are 

able to note progress over time. 

Educate Patients and Family Members To Serve as Advocates 

Patient education needs to be a major focus in medication reconciliation. Patients may not be 

accurate historians.32 Recognition that information is being gathered from laypeople needs to be 

acknowledged and assistance needs to be offered to make the information as accurate as 

possible. A number of approaches have been identified to assist patients and families—for 

example, reconcile the medication list at every ambulatory visit.9

 Establish a process where 

patients bring their medications, including all over-the-counter preparations, to every health care 

encounter.9, 33 Use of a universal patient medication form has shown promise in North Carolina; 

the form can be found at www.scha.org. In addition, educating patients about their medications 

allows them to keep better track of the medications they are taking. 

Challenges 

There are many challenges associated with implementation of effective medication 

reconciliation programs across the continuum of care. First, developing and implementing 

effective programs is very complex considering the various sites of care, the need for 

standardization in the process, and the importance of including the patient in the process. 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Garnering executive leadership and support, obtaining physician and nurse understanding of the 

need for medication reconciliation, and actively participating in the design and implementation 

of programs may be difficult in many organizations where providers already feel burdened. 

There is a time commitment in both obtaining the medication history and completing the 

reconciliation process. 

Research Implications 

Research is needed on all aspects of the medication reconciliation process to provide an 

evidence base for impacting the prevention of adverse drug events. The Institute of Medicine 

report Preventing Medication Errors1 found that currently most of the studies reported in the 

literature have small sample sizes and are single-site quality improvement projects. Multisite 

studies across the continuum of care are needed to assess the scope of the problem. Intervention 

studies using a variety of approaches, both paper based and electronic, are needed to determine 

the accuracy, feasibility, and simplicity of maintaining accurate lists of a patient’s medication 

history. 

The medication reconciliation process takes time, initially an additional 30 to 60 minutes per 

admission.15 If an inpatient unit has multiple discharges and admissions, this can translate to the 

need for additional full-time staff. If nurses are responsible for the process, nursing hours per 

patient day may need to increase. Study of how medication reconciliation processes change the 

workflow and time associated with it are needed. 

 Busy clinicians are resistant to changing their workflow. Designing and testing streamlined 

processes that will work across the continuum of care, from the ambulatory to the inpatient 

setting, and having all stakeholders involved in the design will facilitate the process. 

Studies of the sustainability of medication reconciliation processes need to be carried out. 

What does it look like at 6, 12, and 24 months? Are improvements being maintained? 

Patients need to be full partners and self-advocates in the medication reconciliation process. 

Studies on systematic, multifaceted education programs regarding how to best maintain a current 

and complete listing of all medications need to be undertaken, as recommended in Preventing 

Medication Errors.

1

 Studies should also address what techniques (e.g., the use of a medication 

card) work best to maintain an accurate list of medications. 

Conclusion 

There is some evidence to demonstrate how a medication reconciliation process is effective 

at preventing adverse drug events. Few studies have been published demonstrating how to do the 

process effectively or outlining the costs associated with design and implementation of 

programs. Nonetheless, an effective medication reconciliation process across care settings—

where medications a patient is taking are compared to what is being ordered—is believed to 

reduce errors. Comparing what is being taken in one setting with what is being prescribed in 

another will avoid errors of omission, drug-drug interactions, drug-disease interactions, and other 

discrepancies. Medication reconciliation is a major component of safe patient care in any 

environment. 

8
Medication Reconciliation

Search Strategy 

Searches were carried out using the terms “medication reconciliation,” “medication 

verification,” “medication safety” “medication systems,” and “medication errors.” OVID 

databases for CINAHL®, MEDLINE®, and Google databases were searched. English-language 

health care literature from 1965 through March 2007 was reviewed. Additional searches were 

carried out on numerous patient safety Web sites, such as the Institute for Safe Medication 

Practices, the National Patient Safety Foundation, the Joint Commission, and the Institute for 

Healthcare Improvement. Reference lists from articles on medication reconciliation were also 

used to identify additional publications. 

Articles that describe various components of the reconciliation process were found. Studies 

tended to be about one of the steps in the handoff process, such as admission from home to an 

acute care facility. No studies were identified that described the reconciliation process along the 

entire continuum of care from admission to an acute care facility, transfer from one level of care 

to another (such as critical care to general care), and discharge back to the community to the 

primary care practitioner or skilled care facility. The majority of articles were descriptive, and 

published studies were primarily quality improvement projects with small sample sizes limited to 

single clinical sites. 

Author Affiliation 

Jane H. Barnsteiner, Ph.D., R.N., F.A.A.N., professor of pediatric nursing, University of 

Pennsylvania School of Nursing, and director of nursing translational research, Hospital of the 

University of Pennsylvania. E-mail: barnstnr@nursing.upenn.edu. 

References

1. Institute of Medicine. Preventing medication errors. 

Washington, DC: National Academies Press; 2006. 

2. Bates DW, Spell N, Cullen DJ, et al. The costs of 

adverse drug events in hospitalized patients. 

JAMA1997; 277:307-11. 

3. Rozich JD, Howard RJ, Justeson JM, et al. Patient 

safety standardization as a mechanism to improve 

safety in health care. Jt Comm J Qual Saf 2004; 

30(1):5-14. 

4. Gleason KM, Groszek JM, Sullivan C, et al. 

Reconciliation of discrepancies in medication histories 

and admission orders of newly hospitalized patients. 

Am J Health Syst Pharm 2004; 61:1689-95. 

5. The Joint Commission. Medication reconciliation. 

sentinel event alert, Issue 35. 2006. 

http://www.jointcommission.org/SentinelEvents/Senti

nelEventAlert/sea_35.htm. 

6. JCAHO, 2005 National Patient Safety Goals. 

Available at: 

http://www.jointcommission.org/PatientSafety/Nation

alPatientSafetyGoals/05_npsgs.htm 

7. Bayley KB, Savitz LA, Rodiquez G, et al. Barriers 

associated with medication information handoffs. In: 

Advances in patient safety: from research to 

implementation Vol. 3. Rockville, MD: Agency for 

Healthcare Research and Quality; 2005. AHRQ 

Publication No. 050021-3. 

8. Lau HS, Florax C, Porsius AJ, et al. The completeness 

of medication histories in hospital medical records of 

patients admitted to general internal medicine wards. 

Br J Clin Pharmacol 2000; 49(6):597-603. 

9. Ernst ME, Brown GL, Klepser TB, et al. Medication 

discrepancies in an outpatient electronic medical 

record. Am J Health Syst Pharm 2001; 58:2072-75. 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

10

10. Miller LG, Matson CC, Rogers JC. Improving 

prescription documentation in the ambulatory setting. 

Fam Pract Res J 1992;12:421-9. 

11. Bedell SE, Jabbour S, Goldberg R, et al. Discrepancies 

in the use of medications. Arch Intern Med 2000;

160:2129. 

12. Manley HJ, Drayer DK, McClaran M, et al. Drug 

record discrepancies in an outpatient electronic 

medical record: Frequency, type, and potential impact 

on patient care at a hemodialysis center. 

Pharmacotherapy 2003; 23(2):231-239. 

13. Vira T, Colquhoun M, Etchells E. Reconcilable 

differences: correcting medication errors at hospital 

admission and discharge. Qual Saf Health Care 

2006;15:122-6. 

14. Chevalier BA, Parker DD, MacKinnon NJ, et al. 

Nurses’ perceptions of medication safety and 

medication reconciliation practices. Nurs Leadersh 

2006;19(1):61-72. 

15. Rozich JD, Resar RK. Medication safety: one 

organization’s approach to the challenge. J Clin 

Outcomes Manag 2001;8(10):27-34. 

16. Stover P, Somers P. An approach to medication 

reconciliation. Am J Med Qual 2006;21:307-9. 

17. Bkiowski, R.M., Ripsin, C.M., Lorraine, V.L. 

Physician-patient congruence regarding medication 

regimens. J Am Geriatr Soc 49(10):1353-7. 

18. Nickerson A, MacKinnon NJ, Roberts N, et al. Drugtherapy problems, inconsistencies and omissions 

identified during a medication reconciliation and 

seamless care service. Healthc Q 2005;8:65-72. 

19. Rogers G, Alper E, Brunelle D, et al. Reconciling 

medications at admission: safe practice 

recommendations and implementation strategies. Jt 

Comm J Qual Saf 2006;32:37-50. 

20. Pronovost P, Weast B, Schwarz M, et al. Medication 

reconciliation: A practical tool to reduce the risk of 

medication errors. J Crit Care 2003;18(4):201-5. 

21. Pronovost P, Hobson DB, Earsing K, et al. A practical 

tool to reduce medication errors during patient transfer 

from an intensive care unit. J Clin Outcomes Manag 

2004 11:2633. 

22. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse 

events due to discontinuations in drug use and dose 

changes in patients transferred between acute and 

long-term care facilities. Arch Intern Med 

2004;164:545-50. 

23. Moore C, Wisnivesky J, Williams S, et al. Medical 

errors related to discontinuity of care from an inpatient 

to an outpatient setting. J Gen Intern Med 2003;18(8): 

646-51.

24. Sullivan C, Gleason KM, Rooney D, et al. Medication 

reconciliation in the acute care setting: opportunity 

and challenge for nursing. J Nurs Care Qual 2005; 

20(2):95-98. 

25. Paquette-Lamontagne M, McLean WM, Besse L, et al. 

Evaluation of a new integrated discharge prescription 

form. Ann Pharmacother 2002;35:953-8. 

26. Wagner MM, Hogan WR. The accuracy of medication 

data in an outpatient electronic medical record. J Am 

Med Inform Assoc 1996;3:234-44.25. 

27. DeCarolis DD, Leraas MC, Rowley C. Medication 

reconciliation upon admit using an electronic medical 

record. Pharmacotherapy 2005;25:1505. 

28. Kramer JS, Hopkins PJ, Rosendale JC, et al. 

Implementation of an electronic system for medication 

reconciliation. Am J Health Syst Pharm 2007;64:404-

22. 

29. The case for medication reconciliation—adapted from 

the Institute for Healthcare Improvement's Getting 

started kit: prevent adverse drug events (medication 

reconciliation) how-to-guide. Nurs Manage 

2005;36(9):22. Available at: http://www.ihi.org/IHI/ 

Programs/Campaign. Accessed August 6, 2006. 

30. Whittington J, Cohen H. OSF helathcare’s journey in 

patient safety. Qual Manag Health Care 2004; 

13(1):53-59.

31. Barnsteiner JH. Medication reconciliation: transfer of 

medication information across settings—keeping it 

free from error. Am J Nurs 2005; 105(3 Suppl):31-6. 

32. Rodehaver C, Fearing D. Medication reconciliation in 

acute care: ensuring an accurate drug regimen on 

admission and discharge. Comm J Qual Saf 

2005;31(7):406-13. 

33. Jacobson J. Ensuring continuity of care and accuracy 

of patients' medication history on hospital admission. 

Am J Health Syst Pharm 2002;59:1054-5. 

34. Bates D, Miller EB, Cullen DJ, et al. Patient risk 

factors for adverse drug events in hospitalized 

patients. ADE Prevention Study Group. Arch Intern 

Med 1999;159(21):2553-2560. 

35. Winterstein AG, Hartzema AG, Johns TE, et al. 

Medication safety infrastructure in critical-access 

hospitals in Florida. Am J Health Syst Pharm 2006; 

63(5):442-450.
Evidence Table. Medication Reconciliation

Study Aim Design & Sample Site 

Bates 199934 Assess strength of patient 

risk factors for adverse drug events (ADEs) 

Nested case control 4,108 admissions 

11 medical and surgical units in 2 tertiary care hospitals 

Adverse drug esicker patients Few risk factorcontrolling for llength of stay. should focus osystems. 

Bayley 20057 Enhance understanding of 

how patient handoffs are related to risk of adverse medical events before and after implementation of an information technology solution 

Informant interviews One primary care 

practice and four inpatient facilities (one academic medical center and three community hospitals) 

Based on themdata, identified to work procesindividual discrdesigning effec

Bedell 200011 Examine frequency of 

discrepancy between medications prescribed and those taken and associated causal factors. Compare medication containers and reported use of medication with medical records 

Descriptive design 312 medical records in ambulatory setting 

5 cardiology and 3 internal medicine practices 

545 discrepanc(76%) 278 (51%) takichart 158 (29%) not 109 (20%) takichart. Predictors of dnumber of med

Boockvar 200422 Identify medication changes 

during transfer between hospital and nursing home and ADEs caused by these changes 

Descriptive study of residents of 4 nursing homes admitted to 2 academic hospitals. Nursing home and hospital records reviewed to identify changes in medication regimens between sites. Medications matched and compared regarding dosage, route, and frequency of administration

 4 nursing homes During 122 adm

numbers of metransfer from nand hospital to and 1.4, respein drug use wechanges and cbidirectional trato medication c14 (20%). Ovealteration (n=3medication chacausing ADEs most ADEs (12nursing home areadmission.

11
12

Study Aim Design & Sample Site 

Chevalier 200614 Measure nurses’ perceptions of patient safety, medication safety and current medication reconciliation practice at transition points in a patient’s hospital stay Descriptive survey of 111 nursing staff Three general medicine units Inconsistent m

completion due lack of commuprofessionals. DeCarolis 200527 Compare usual process of obtaining medication history to systematic reconciliation process Comparison of pharmacist obtained medication history to inpatient medical record and computerized outpatient medical profile. 1 VA medical center 71% of patient

computerized pdiscrepancies Medication recunintended ord

Ernst 20019 Assess accuracy of data in the EMR and document frequency and types of discrepancies that occurred. Compared prescription renewal requests with electronic medical record data. 950 prescription- renewal requests for 134 medications over 3 month period. Family Medicine Outpatient Clinic Medication dis

250 (26.3%) rediscrepancies patient was takordered in the 

Gleason 20044 Identify type, frequency, and severity of medication discrepancies in admission orders. Assess whether pharmacist obtained admission med histories decreased number of med errors. Convenience sample compared 204 pharmacist conducted medication histories from patients to medication and allergy history documented in patient charts 725 bed tertiary care academic medical center. Direct admissions to 12 adult medical- surgical units Interviews took 

Discrepancies admission medmore than 50% have been har

Kramer 200728 Establish feasibility of electronic system for 

pharmacist and RN admission and discharge medication reconciliation and assess effect on patient safety, cost, satisfaction among providers and nurses 

Pre-post electronic reconciliation process 

283 patients on general medicine unit, 147 in preimplementation phase and 136 in postimplementation phase. 

Preimplementaincomplete medosage changePost implemenallergies were completed signchanges and plevel of agreemmedication instLack of MD pacomplete elect
13

Study Aim Design & Sample Site 

Lau 20008 Compare medication history 

in hospital medical record with community pharmacy records prior to admission 

Prospective observational study of 304 patients 

General medical units of 2 acute care hospitals 

61% of patientcommunity phamedication histmedications in were not listed records. 

Manley 200312 Determine rate of drug 

record discrepancies in a hemodialysis population 

Prospective observational study of 63 patients 

Outpatient hemodialysis center 

60% of patientdiscrepancies. 

Miller 199210 Improve family practice office 

chart documentation of prescribed medications through use of duplicate prescription forms 

Descriptive study of implementation of duplicate prescription forms Baseline chart review – 67 charts Duplicate prescription form: 1 week = 50 charts; 40 months = 60 charts 

Ambulatory family practice 

Baseline: 51 paprescribed medcharts with incodocumentation 1 week: 83% oprescription me40 Months: 82% prescription me

Moore 200323 Determine prevalence of 

medical errors from inpatient to outpatient setting 

Descriptive study of 86 patients inpatient and ambulatory medical records 

950 bed urban teaching hospital and affiliated primary care practice 

42% of patientcontinuity error 

Nickerson 200518 Determine clinical impact on 

drug therapy problems (DTP) of pharmacist review of discharge medications at discharge 

Randomized clinical trial with 6 month followup of 253 patients 

2 inpatient family practice units 

Pharmacist inteaverage per pagroup retrospe56% had DTP 

Paquette-Lamontagne 200225 Improve accuracy of patient profile information in 

community pharmacies with use of discharge prescription forms 

Quasi experimental intervention with 89 patients 

Medical units in 3 teaching hospitals 

82% of medicaexperimental gcompared to 4

Pronovost 200320 Reduce medication errors 

with a reconciliation process using paper form at discharge fro surgical ICU 

Intervention using paper medication discharge form for ICU discharges 

Surgical ICU At baseline 94% 

were changed Week 24 disch

Pronovost 200421 Reduce medication errors 

with a reconciliation process using an electronic form at discharge from surgical ICU 

Intervention using electronic medication discharge form for ICU discharges 

1,455 patients in surgical ICU over 1 year period 

21% of patientorder change. discrepancy 
14

Study Aim Design & Sample Site 

Rozich 200115 Rozich 20043 Reduce medication discrepancies at health care transition points through the implementation of a medication reconciliation process on admission, during transfer and at discharge from the hospital Descriptive study of implementation of medication reconciliation process Acute care inpatient units Baseline 20 charts per week for 6 weeks the ongoing chart review Baseline medic

213 per 100 ad7 month post inreconciliation p100 admission

Vira 200613 Describe potential impact of medication reconciliation process to identify and rectify errors at time of hospital admission and discharge 60 randomly selected patients. Compared admission medication orders with patient medication vials and interviews with patients, caregivers and outpatient health care providers. At discharge, pre-admission and in patient medications compared with discharge orders and written instructions. Inpatient community hospital 60% of patient

unintended varminimum of 1 cvariance. None reconciliation p

Wagner 199626 Assess correspondence between medications the patient taking and documentation in EMR Descriptive comparison of patient report and chart review study of 312 medical records Outpatient geriatric center Mean number 

5.67 Mean number EMR: 4.69 Missing medicato patient misrefailure to note EMR (26%) Whittington 200430 Reduce percentage of admission ADEs caused by 

errors in reconciliation through use of admission reconciliation form as hospital medication record and discharge prescription form 

Descriptive study of implementation of medication reconciliation process Number of patients enrolled not reported 

4 hospitals Change from 4

medication list reconciliation p

Winterstein 200635 Evaluate medication safety 

infrastructure of criticalaccess hospitals in Florida 

Qualitative assessments using self-administered survey and site visits of 7 hospitals. 

7 critical access hospitals in Florida 

Characteristics improvement inreconciliation. infrequently revwere associateof medication e