What’s New in the Patient Safety World

September 2012

Good News on Medication Reconciliation



After a series of articles with not-so-good conclusions regarding medication reconiciliation, we’ve finally seen some good news. First, a recent large randomized clinical trial (Kripalani 2012) showed that over 50% of patients with cardiac conditions discharged from hospitals had one or more clinically significant medication errors and that a health-literacy–sensitive, pharmacist-delivered intervention did not reduce post-discharge medication error rates. Then a recent systematic review of medication reconciliation practices in hospitals (Mueller 2012) highlighted the relative paucity of high quality evidence supporting best practices for medication reconciliation. They concluded that the best evidence supports use of pharmacy staff in the medication reconciliation process and targeting high-risk patients. But for most other approaches, there is a relative paucity of evidence demonstrating desired outcomes.


But a new study from Johns Hopkins (Feldman 2012) has more promising news using a nurse-pharmacist team to do medication reconciliation. They found that a dedicated nurse interviewing the patient and/or contacting the patient’s PCP or pharmacy or reviewing the EMR was able to identify unintended discrepancies from the home medication list compiled by the physician on admission in almost 50% of patients. The nurse would then discuss those discrepancies with a consulting pharmacist and the physician to come up with the best medication list. Such discrepancies were slightly less common on discharge but those found on discharge had higher risk of causing harm to the patient. They provided a cost analysis of the program and concluded that it cost about $32 per patient or $114 to uncover one potentially harmful discrepancy. Using a figure from the literature of $9300 to manage each case with harmful events, they conclude that the program justifies itself financially many times over.


An editorial accompanying the Mueller review (Kaboli 2012) reinforces that targeted interventions are probably most cost-effective.  They advocate for targeting highest-risk patients for medication reconciliation but note the need to balance this against the need to provide safe medication practices for all patients.


There is more to medication reconciliation that just identifying what medications the patient is taking at home. One field we commonly see missing on medication reconciliation forms is “time last dose taken”. While that may be less relevant for drugs like daily statins, it is very relevant for drugs like insulin, anticoagulants, or cardiovascular medications that affect blood pressure or heart rate. Add to that the nuances of various hospital pharmacy dispensing systems that relate time of the order to time a medication may be given. For example, some hospitals might dispense/administer their “once daily” medications every morning at 8:00 AM. In such cases, a patient admitted at 8:30 AM may not get his/her dose of that medication until 8:00 AM the following morning. In the old days a physician would handwrite orders and given them to a nurse who would often ask “do you want the patient to get a dose today?”. Nowdays, with CPOE that step is often lost and there may be no warning on the CPOE system that such medications won’t be given until the next morning.






Feldman LS, Costa LL, Feroli ER, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med 2012; 7(5): 396-401




Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-Based Medication Reconciliation PracticesA Systematic Review. Arch Intern Med. 2012; 172(14): 1057-1069




Kaboli PJ, Fernandes O. Medication ReconciliationComment on “Hospital-Based Medication Reconciliation Practices”. Arch Intern Med. 2012; 172(14): 1069-1070




Kripalani S, Roumie CL, Dalal AK, et al. Effect of a Pharmacist Intervention on Clinically Important Medication Errors After Hospital Discharge: A Randomized Trial

Ann Intern Med 2012; 157(1): 1-10
















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