Patient Safety Tip of the Week


September 8, 2009    Barriers to Medication Reconciliation



Healthcare Quarterly, published by Longwoods Publishing of Canada, is a little-known resource that contains a wealth of great information. Though every issue has some articles that are of general interest, at least once a year they publish a special edition with patient safety papers. One of the papers in the most recent special edition (Coffey et al 2009) looked at the implementation of admission medication reconciliation at two Canadian academic medical centers, one a general tertiary care center and the other a pediatric tertiary care center. The approaches taken at the two centers differed but both encountered similar barriers and themes during implementation and provide some very valuable lessons learned.


Both centers began with a medication reconciliation form to be filled out by physicians on admission. This form had spaces for the medications to be entered and then reconciled by checking either “continue”, “stop”, or “change”. The paper discusses the various strategies for compilation of the best possible medication history (BPMH) and reconciling the medications, such as using pharmacists or nurses for the various roles. The availability of resources, particularly clinical pharmacists, largely determined the roles at each hospital. However, the nature of the patient population was also important in the program design. Both hospitals developed screening processes to identify patients for independent BPMH and reconciliation by a pharmacist. The general hospital had previously identified that a high rate of medication discrepancies occurred in patients on four or more medications (Cornish et al 2005) so they focused their medication reconciliation efforts on patients meeting this criterion plus patients on a high alert medication or patients with an unclear medication history. Three quarters of their patients met those criteria, whereas only one quarter of those at the pediatric hospital met those criteria.


Both initially tried to have physician leaders orient all members of medical teams to use of the Med Rec forms. However, within a few months they realized that was not going to work. There was too much turnover of medical staff and the physician leaders were not always available. In addition, though the Med Rec forms were present at both hospitals, physicians often did not know where to look for them, forgot about them, or just left them blank. Most importantly, they were often looked upon as extra work or duplicate effort (since they were already listing the medications in their History and Physical). Recognizing these barriers, the general hospital added pharmacist staff and encouraged pharmacists to initiate the Med Rec process as early as possible in the admission process (often in the emergency department). At the pediatric hospital nurses were trained to do the BPMH and reconciliation. Interestingly, when nursing began doing these processes there was a precipitous dropoff in physician compliance with the Med Rec process. They use this as an argument against making Med Rec too dependent upon a particular individual. They subsequently relaunched their educational efforts with the physician leader and a resident champion plus began feedback with physician-specific compliance rates and saw an improvement physician compliance, though rates for physician compliance with both steps is in the 40-60% range.


They summarize several lessons lessons learned:

  • Physicians don’t like to document medication history separately from the History and Physical.
  • Constant turnover residents and staff physicians makes the educational effort difficult.
  • Workload demands on both pharmacists and nurses are substantial.
  • Data collection and auditing are labor-intensive and burdensome.
  • Participation in the Safer Healthcare Now! Initiative in Canada was a success factor.
  • The regulatory requirement for medication reconciliation in the hospital accreditation process was a significant accelerator of the process.
  • Seeing the benefit of having the BPMH at the time of discharge improved acceptance.
  • Having a strong physician leader and supportive management culture on some units (eg. cardiology) led to high rates of immediate compliance.
  • When there is shared accountability, you must clarify which team members are accountable for which steps.


We’ll add some of our own comments. First, we fully agree that duplication of documentation is a real problem. Physicians (and everyone, for that matter) do not want to write out all the medications in their History and Physical, the Medication Reconciliation Form, and the admission order sheet/form. So why not merge them? One hospital we have worked with uses the medication reconciliation form as the admission medication order form. It is structured so that the physician checks which of the past medications should be continued on admission and then the physician adds any additional medications below those. Note that this concept can be used when order entry is either by paper or CPOE. Then, when writing or dictating their History and Physical, the physician can simply reference that list by stating “refer to the medication reconciliation form for medication history”. So that is a time saver. Does it have a downside? Yes, we find some physicians refer to the form even when it has not, in fact, been completed.


Second, time of last dose is a very important element during medication reconciliation that is most often overlooked. Failure to record it results in either omission of doses or duplication of doses. It is unrealistic to think that you will get this filled out for every medication and it will be of little consequence for many medications. However, especially for high alert medications (such as insulin, warfarin, cardiac medications, anticonvulsants, psychiatric medications, narcotics, sedatives, etc.) it is very important to record the time of the last dose.


Third, availability of the medication reconciliation sheet to all relevant clinical staff is critical. Frequent readers of this column know we have often pointed to the unintended consequences of healthcare information technology. One of those is that a paper-based medication reconciliation form is often located only in the paper chart. Other healthcare workers that should have easy access to this often now only use the computer system to access patient information. For instance, pharmacists may know that the Med Rec form is in the chart but if they have to interrupt their busy routine to walk up to the patient floor to see it they are not likely to do so. So if you don’t make your Med Rec form part of your EMR (electronic medical record), at least send or fax a copy of it to your pharmacist with the admission orders. Note that if you made the Med Rec form the admission order form as above, you wouldn’t have this problem.


Fourth, we like the concept of focusing the medication reconciliation process to high risk patients. That, in theory, could cut down considerably on the workload imposed by the need to do medication reconciliation. However, as noted in the Coffey paper, three quarters of the patients in a typical adult general hospital would likely meet the criteria for high risk. So we wonder how much work would be reduced by such an approach. We would prefer the universal approach to medication reconciliation and we’ll likely need to make better use of information technology to accomplish this and reduce workload at the same time. However, remember our caveats in our December 30, 2008 Patient Safety Tip of the Week “Unintended Consequences: Is Medication Reconciliation Next?”. Of interest in this light is the recent paper from Partners Healthcare in Boston (see Schnipper et al 2009) which used an IT solution and redesign of its medication reconciliation process. They demonstrated an overall 28% relative risk reduction in unintentional medication discrepancies with a potential for harm (though the reduction was seen for discharge but not admission). Interestingly, they found more success for the intervention in patients deemed to be at high risk for medications discrepancies (using a risk score developed from their control population but not yet validated). It will be most interesting to see if that risk score can be validated in other populations so that it could be used as a flag for patients needing more intensive efforts at medication reconciliation.


Fifth, one of our pet peeves is the failure to record indication for a drug (or reason for discontinuation of a drug). On admission, not knowing the reason a patient is taking a drug may lead to erroneous management of that drug. For example, a patient taking digoxin for heart rate control may require different digoxin dosing and target levels than someone with CHF taking it for its inotropic effect. Or the target INR levels in patients on warfarin may differ depending on the reason for anticoagulation.


Sixth, the answer to the recurring question “who is responsible for medication reconciliation?” is “everyone is”. While it’s easy to say that the physician is ultimately responsible, it is clear that almost everyone involved in a patient’s care (the physician, nurse, pharmacist, and patient himself) have important roles in medication reconciliation. When Partners Healthcare (see Schnipper et al 2009) in Boston redesigned its medication reconciliation process, physicians were assigned responsibility for taking preadmission medication histories and referring to this list when ordering medications. However, pharmacists were responsible for confirming the medication reconciliation process at admission and nurses were responsible for confirming the medication reconciliation process at discharge.


Seventh, we often forget to go back and refine our medication reconciliation process. Your BPMH (best possible medication history) or PAML (preadmission medication list) is often incomplete on the day of admission and should be further refined on subsequent days by contacting family, primary care providers, etc. Yet we often forget to do this. Note that the same applies to allergy lists, etc. In one study of medication reconciliation in trauma patients (Schenkel 2008), admission medication lists were highly inaccurate. The median duration of the medication reconciliation process was 2 days. And 25% required 3 or more days. So you need some sort of flag or tickler to tell you to go back and complete this step. For instance, there is a big difference between “no known allergies” and “no adequate historian available to provide allergy information”. Particularly with electronic medical records, you can set a flag based on the latter that will prompt a caregiver on Day 2 (or later) to go back and attempt to get this information. We recently saw a discharge medication reconciliation sheet that started with the comment “unable to get medication history” despite the fact that multiple medications were prescribed during the hospital course that obviously were being taken prior to admission. So don’t forget to go back and capture this key information if you could not get it at the time of admission.


Eighth, we agree that shared accountability creates problems. We see that when physicians co-manage patients they often assume the “other” physician will do something and both fail to do what is necessary. The same applies to a Med Rec process where responsibilities are shared. Therefore, you need to make it clear up front what you expect the physician, the nurse, and the pharmacist to do in the process.


Ninth, demonstrating value of the BPMH list downstream is an important factor in getting physician buy-in to do this on admission. So when a physician is discharging or transferring a patient from one service to another and sees how the BPMH and Med Rec form can facilitate those events, they are more likely to do a BPMH themselves. However, often the emergency department physician is the first to begin a BPMH and they may not perceive the same value in this list.


Tenth, doing medication reconciliation well is resource-intense. But it has a significant return on investment not only from a patient safety perspective but also from a financial perspective. The Northwestern Memorial Hospital website has an excellent page “Making the Case for Medication Reconciliation”. Our October 23, 2007 Patient Safety Tip of the Week “Medication Reconciliation Tools” also provides links to some of the ROI tools.




See also our previous columns on medication reconciliation:





Implementation of Admission Medication Reconciliation at Two Academic Health Sciences Centres: Challenges and Success Factors.




Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med. 2009; 169: 771-780



Northwestern Memorial Hospital. Making the Case for Medication Reconciliation.



Schenkel  S. The Unexpected Challenges of Accurate Medication Reconciliation. Annals of Emergency Medicine 2008; 52(5): 493-495











Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive