Reducing medication discrepancies

Pharmacists empowered to edit med lists

Using a multidisciplinary medication reconciliation process can reduce the number of medication discrepancies that occur during admission and discharge.

That's the conclusion of researchers at the Mayo Clinic College of Medicine in Rochester, MN, who define medication reconciliation as the process of identifying the most accurate list of all medications a patient is taking, including the name, dosage, frequency, and route of each medication, and using that list to provide correct medications for the patient anywhere within the health care system.

"Experience from multiple organizations has shown that a lack of medication reconciliation accounts for 46% of all medication errors and up to 20% of adverse drug reactions in the hospital setting," says lead researcher Prathibha Varkey, MD, MPH. "To initiate medication reconciliation at the Mayo Clinic … we pilot tested a structured medication reconciliation program in the academic family medicine hospital service."1

Before the study, there was no formal medication reconciliation process in place in the study unit. Medications were reviewed by medical residents at admission, but pharmacists and nurses did not formally review home medications with patients.

As part of the study, an admission medication section was added to the electronic medical record in the hospital summary. During patient admission, direct care nurses recorded the patient's home medication use, taking information from patients, family members, and medication bottles. Nurses, pharmacists, and physicians used an admission medication reconciliation form to reconcile patients' home medications.

After completing the outpatient medication history, the nurse placed the medication reconciliation form on the patient's chart. The unit pharmacist collected the forms on the charts of new admissions, compared the nursing admission medication history to the admission medications ordered by the admitting resident, and noted any discrepancies. The admission medication reconciliation form was also reviewed during morning patient rounds by the attending family medicine physician, who reconciled the discharge medication list. Any corrections that needed to be made to hospital admission orders were communicated to the respective medical resident and the entire medication reconciliation process was completed within 24 hours of patient admission.

Later, the discharge medication list in the hospital summary was compared against the patient's home medications list, inpatient medication profile (active medication orders on the day of hospital discharge), and prescriptions documented in the electronic medical record to investigate any medication discrepancies. The discharge medication list included medications received during hospitalization to be continued after discharge, new medications added to the patient's regimen, and any medications that were to be discontinued. Changes to pre-admission medications, new medications ordered upon hospital discharge, and discontinued medications were to be specifically noted on the discharge sheet.

Pharmacists documented discrepancies

Pharmacists participating in the study documented and categorized medication discrepancies by the potential severity of the error. In addition to inaccurate medication information, the omission of newly prescribed medications and the lack of notation of discontinued and changed medications were considered discrepancies because of the potential for harm.

In a second phase of the study, the processes established in the first phase were continued, but family medicine medical residents and staff consultants were instructed to include reconciled admission and discharge medication lists in the hospital summary.

The researchers found that discrepancies occurred more commonly during discharge than during admission. Patient length of stay and the number of medications patients were taking were also associated with higher numbers of discrepancies.

Before the reconciliation process was implemented, 0.5 discrepancies per patient were found on the admission medication list and 3.3 discrepancies per patient on the discharge medication list. The researchers said the discrepancies may have occurred because residents forgot to include home medications on the discharge list that were discontinued on admission to the hospital. The discrepancies also could be linked to the study's strict definition of a discharge medication discrepancy.

The study indicates that a standardized medication reconciliation process using a multidisciplinary approach, academic detailing, cross-checks, audits, and feedback led to a reduction in medication discrepancies. Along with a decrease in the number of discrepancies after the medication reconciliation process was established, the researchers also noted a decrease in the severity of discrepancies that did occur.

The researchers said pharmacists were an outstanding resource for nurses, residents, and consultants as reconciliation was performed through various stages of a hospital stay. During the study, pharmacists had to enhance the quality of the nursing medication lists with additional information on several occasions. After study results were disseminated, pharmacists at Mayo were empowered to edit patient medication lists in the electronic hospital summary in collaboration with prescribers to enhance accuracy. Also, pharmacists have begun taking medication histories for patients being admitted to the hospital.

Patient education needed

Although the study did not specifically target improvement efforts at patients, the researchers note that another study recently found that less than 30% of patients were able to list the medications they were taking at the time of hospital discharge. Patients must be taught, the researchers said, about the importance of an accurate and updated medication list, including non-prescription medications and herbal supplements, as well as the importance of bringing medication bottles or the most current medication list to every provider visit or hospital at admission.

Another study at the Toronto General Hospital, University Health Network, and the Leslie Dan Faculty of Pharmacy at the University of Toronto, found that involving pharmacists in obtaining and assessing a patient's medication history before elective surgery can significantly reduce medication discrepancies upon admission.2

"Reconciling a patient's home medication regimen with drugs prescribed in the hospital is difficult," said lead researcher Olavo Fernandes, PharmD, pharmacy clinical site leader at Toronto General Hospital and an assistant professor at the pharmacy school. "We're also seeing sicker patients who are being treated for multiple illnesses. What this study clearly tells us is that involving pharmacists in the assessment of patients' home medications before surgery can reduce medication discrepancies in hospitals."

In the study, pharmacists worked with nurses in the surgical pre-admission clinic to interview and assess patients' home medication history. The assessments were used to support surgeon prescribing of patients' home medications with a postoperative home medication order form. If needed, the pharmacist followed-up with the patient's community pharmacy or family physician to clarify the medication regimen and ensure accuracy. The control portion of the study involved nurses taking medication histories and surgeon-generated orders without preadmission pharmacist medication assessments and generation of the postoperative home medication order form.

The study found a 50% reduction in medication discrepancies upon hospital admission after surgery. The most common medication discrepancy was omission of reordering home medications. Results also demonstrated that 29.9% of patients with standard care (not having the pharmacist involvement) had at least one postoperative medication discrepancy with the potential to cause "possible" or "probable harm" compared with 12.9% of those who had pharmacist involvement. Clinicians have said they are optimistic they can reduce medication discrepancies even further with enhancements to the multidisciplinary model.


1. Varkey P, Cunningham J, O'Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm 2007;64:850-854.

2. Kwan Y, Fernandes OA, Nagge JJ, et al. Pharmacist medication assessments in a surgical preadmission clinic. Arch Intern Med 2007;167:1034-1040.

[Editor's note: Contact Dr. Varkey by e-mail at Contact Dr. Fernandez by e-mail at]