What is the definition of medication reconciliation?
The Joint Commission defines medication reconciliation as the process of comparing a patient’s medication orders to all of the medications the patient has been taking in order to identify and resolve medication discrepancies.1
How do you do it?
The Institutes of Healthcare Improvement defines medication reconciliation in three steps:2 :
- Verification: The first step is to obtain a medication history from the patient and other appropriate sources (e.g., caregivers, providers, and dispensing pharmacy) that includes medications the patient is currently taking and those the patient should be taking. The compiled medication list should then be reviewed with the patient or caregiver.
- Clarification: The medications and doses listed should be assessed for appropriateness.
- Reconciliation: The home medication list should then be compared against any new medications ordered during transition periods of a hospital stay or clinic appointment, most notably during admission and discharge.
Who can conduct medication reconciliation?
Pharmacists, certified pharmacy technicians, and pharmacy students are all good candidates with the appropriate knowledge and skills to provide the service.
What products should be included in questioning?
Prescription medications, over-the-counter (OTC) medications, vitamins, herbal supplements, and nutraceuticals.
What information about medications needs to be collected?
Medication name, strength, dosage form (extended release, orally disintegrating tablet, cream, aerosol, solution including injections, etc.), dose, route of administration (oral [PO], inhalation, topical, intramuscular [IM], subcutaneous [SQ], intravenous [IV], etc.), frequency and time of administration (once daily, twice daily in the morning and at bedtime, etc.), duration (for 10 days, indefinitely, etc.), time of last dose, and date of last prescription fill.
What are common findings as a result of medication reconciliation?
- Omission – a medication the patient is currently taking is not listed
- Commission – a medication is listed, but patient is not currently taking
- Different dose or route or frequency is listed of a medication the patient is taking
- Patient is taking a medication without the indication (diagnosis)
- Therapeutic duplication (patient is taking multiple drugs from same therapeutic class)
Why is completing medication reconciliation important?
- Adverse drug events are discovered as well as duplicate therapy that puts the patient at risk for additional side effects and adverse events.
- Star Ratings Measure C09: Care for Older Adults – Medication Review (Medicare Special Needs Plan only)
Percent of plan members whose doctor or clinical pharmacist has reviewed a list of everything they take (prescription and non-prescription drugs, vitamins, herbal remedies, other supplements) at least once a year.
4 stars > 88% to < 93%
5 stars > 93%
- Star Ratings Measure C20: Medication Reconciliation Post-Discharge
Percent of plan members whose medication records were updated within 30 days after leaving the hospital. To update the record, a doctor (or other healthcare professional) looks at the new medications prescribed in the hospital and compares them with the other medications the patient takes. Updating the medication records can help to prevent errors that can occur when medications are changed.
4 stars > 55% to < 68%
5 stars > 68%
What barriers do health plans need to address for medication reconciliation?
- Health plans must have access to timely information about members’ acute care admissions and discharges.
- Clinical case managers must address those members most at risk for readmission or adverse drug events (diagnosis, number of medications, age, frailty, absence of caregiver, mental health diagnosis).
- Clinical case managers must receive timely results of medication reconciliation to confer with other members of the interdisciplinary care team and resolve identified problems.
What is the difference between medication reconciliation and medication therapy management?
- Medication therapy management (MTM) is a Centers for Medicare & Medicaid Services (CMS)-required program with eligibility criteria based on drug spend, number of medications, and number of chronic conditions.
- The Comprehensive Medication Review (CMR) required as a part of the MTM Program includes medication reconciliation, and a copy of the CMR must be provided to the member.
- Medication reconciliation needs to be completed upon each and every acute care discharge. MTM Program components include targeted quarterly review as well as an annual CMR.
The Pharmacy and Clinical subject matter experts at Gorman Health Group can assist health plan sponsors to design, implement, train staff, and support medication reconciliation programs. Medication reconciliation can lead to better outcomes and raise Star Ratings measure values: a win-win. Contact me directly at email@example.com.
1. The Joint Commission. National Patient Safety Goals Effective July 1, 2011 Hospital Accreditation Program. http://www.jointcommission.org/assets/1/6/NPSG_EPs_Scoring_HAP_ 20110706.pdf/
2. How-to Guide: Prevent Adverse Drug Events by Implementing Medication Reconciliation. Cambrige, MA: Institute for Health Improvement: 2011. (Available at www.ihi.org). Accessed July 2018
3.Rattray,DJ, Whitner Ver Vaet JB, Lisenby KM. Medication Reconciliation Guidance Document for Pharmacists. ASHP Resource Center/Ambulatory Care/Patient Management and Care Delivery Models. Accessed July 2018
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