JCAHO looking closely at medication reconciliation

Process is not easy but essential for patient safety

An intensive care unit nurse recorded a patient’s daily dose of an antipsychotic agent as 25 mg a day, but the actual dose was one-half a 25 mg tablet. As a result, the patient received a double dosage within 12 hours and became lethargic and confused, resulting in an additional day of hospitalization for observation.

An admitting nurse wrote down a medication list from the physician’s office but did not review it with the patient. The list included two medications which had been discontinued shortly beforehand, but the patient was given these drugs anyway. As a result, the patient’s blood pressure and heart rate dropped sharply, necessitating an overnight stay.

These are just two of more than 2,000 medication reconciliation errors reported in 2005 to the Rockville, MD-based United States Pharmacopeia. In addition, the Joint Commission has issued a sentinel event alert urging organizations to improve efforts to reconcile medications as patients transition from one care setting or practitioner to another.

According to the alert, medication reconciliation should occur whenever a "handoff" occurs, whether to a new caregiver, unit, or facility. If this doesn’t occur, patients may receive duplicative medications, incompatible drugs, or wrong dosages, warns the alert.

According to the Joint Commission’s sentinel event database, 63% of the reported medication errors resulting in death or serious injury were due to breakdowns in communication, and approximately half of those would have been avoided through effective medication reconciliation.


To reduce the risk of errors related to medication reconciliation, the alert recommends the following:

  • Put the list of medications in a highly visible place in the patient’s chart and include essential information about dosages, drug schedules, immunizations, and drug allergies.
  • Reconcile medications at each interface of care, specifically including admission, transfer, and discharge. The patient and responsible physicians, nurses, and pharmacists should be involved in this process.
  • Provide each patient with a complete list of medications that he or she will take after being discharged from the facility, as well as instructions on how and how long to take any new medications. The patient should be encouraged to carry this list and share it with any caregivers who provide any follow-up care.

In addition, as part of its current National Patient Safety Goals, the Joint Commission requires that each accredited health care organization:

  • Implement a process for obtaining and documenting a complete list of the patient’s current medications upon admission, including prescription medications, over-the-counter medications, vitamins, herbs, or other supplements.
  • Communicate a complete list of the patient’s medications to the next service provider when the patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

At OSF St. Joseph Medical Center in Bloomington, IL, the medication reconciliation process was started five years ago as part of an Institute for Healthcare Improvement collaborative on reduction of adverse drug events.

"Medication reconciliation was a key change in that collaborative, and one we have been doing ever since," says Kathy Haig, patient safety officer and director of quality and risk management. Haig credits the medication reconciliation process to a tenfold reduction of adverse drug events that has been sustained for several years.

All three phases of medication reconciliation — admission, transfer, and discharge — are done on inpatient nursing units with 90-100% compliance. "We started with a paper tool and moved to an electronic tool about three years ago," says Haig.

Staff can access the patient’s medication list with the electronic medical record and compare this with current orders to insure all medications, doses, frequency, and routes match. Those that don’t must be clarified with the physician.

The medication list also functions as a physician’s order, so once the physician indicates whether the medication is to be continued, changed, or discontinued, the tool is faxed to the pharmacy.

"This is a win for both the nurses and patient safety, as it eliminates recopying which can lead to transcription errors," says Haig. "We are currently updating the medication reconciliation form in our electronic medical record to make it more user-friendly, neater, and cleaner." Here are the steps that occur for each type of medication reconciliation:

• For admission reconciliation:

The patient’s home medications are entered into the electronic medical record and printed out. The nurse reviews this list with the orders and brings any variances to the physician’s attention. For high-risk drugs such as insulin or anticoagulants, this is done within four hours. The physician then makes any necessary changes and signs the form, which is then faxed to pharmacy as the order.

For transfer reconciliation:

The transferring nurse prints out a copy of the transfer medication reconciliation form from the electronic medical record, including the current hospital medications. The list is attached to the chart prior to sending the patient to another department. The physician reviews this list and either approves the current medications or makes changes and signs the form.

• For discharge reconciliation:

The medication reconciliation list is printed out and placed on the chart for the physician to review and sign prior to the patient’s discharge. "We are also trying to have our unit-based pharmacists review this list to identify potential medication interactions, so that they can be addressed with the physician prior to discharge," says Haig.

Twenty patient records are reviewed by random audit each month by a staff member in the quality resource management department who has been trained in the process. Each phase of medication reconciliation is checked to see that the process was completed and that the information was accurate.

"Medication reconciliation is essential to safe patient care, although it is no easy task," says Monica Ray, RN, BSN, director of quality at Carle Foundation Hospital in Urbana, IL. "Health care has become so fragmented with specialization and the complexity of health care delivery systems that keeping track of patients’ medications is very difficult."

The goal is to ensure patients are on the intended medications across the continuum of care and that all health care providers are aware of the full medication lists at each point of care.

"No one can argue that this is the right thing to do," says Ray. "However, health care systems have not been developed to support this in the past, and it will take time to re-tool and make it an efficient, reliable process," she says.

Quality professionals at Carle Foundation developed comprehensive processes and tools to reconcile medications for admission, post–procedure, transfers, and at discharge. The new medication reconciliation process was implemented in January 2006.

The tools include:

  • an inpatient home medication reconciliation sheet that serves as the medication history, admission, and discharge reconciliation and can be used for most prescriptions if needed.
  • a discharge medication education sheet that the patient receives that lists all medications, medications that are to be stopped, and allergies.
  • The newest tool in development is tailored for the outpatient setting and combines the history, reconciliation, orders and education onto one form. "The same processes are being designed in our electronic medical record, to be fully implemented in the next two years," adds Ray.

Barriers to successful implementation include complex delivery models and incompatible information systems, as well as resistance from some specialists, says Ray.

"Some physicians are reluctant to be accountable for medications they did not originally prescribe and are unfamiliar with," she explains. "Whether we want to admit it or not, there are significant time, trust, and liability factors that exist."

For instance, a surgeon may not want to take the time to review and reconcile a long home medication list, or to be accountable for cardiac medications prescribed by the cardiologist. The surgeon is therefore reluctant to be responsible for ordering previous home medications and making any changes.

To address this problem, the wording on the forms has been revised to reflect that home medications are "reviewed" on admission and at discharge, and each medication is indicated with a check box to 1) resume 2) change or 3) discontinue. Presentations to nursing and medical staff, frequent communication, and one-on-one coaching are other ways to promote medication reconciliation.

Fragmentation of care with use of pre-operative centers, hospitalist services, and specialists makes the process more complicated, adds Ray. "Primary care physicians are most likely to pull all of the medication information together. But we have found this to be difficult as well for many reasons," she says.

Lastly, the flow of information among health care providers, whether manual or electronic, is problematic, says Ray. "Even electronic systems can be incompatible or with limited access. This inhibits freely sharing available information in order to reconcile medications efficiently and accurately," she explains.

Medication reconciliation may be difficult, but it’s not impossible, stresses Ray. "We are facing the challenge head-on, in order to provide the safest care possible for our patients," she says. "Over time, our patients will be better educated and prepared with medication lists when they arrive at a health care facility, to help ensure safe medication management."

[For more information, contact:

Kathy Haig, Director, Quality/Risk Management/Patient Safety Officer, OSF St. Joseph Medical Center, 2200 E. Washington Street, Bloomington, IL 61701. Telephone: (309) 662-3311, ext. 1347. E-mail: Kathy.M.Haig@osfhealthcare.org.

Monica Ray, RN, BSN, Director, Foundation Quality, Carle Foundation Hospital, 611 West Park Street, Urbana IL 61801. Telephone: (217) 383-4877. E-mail: Monica.Ray@carle.com.]