Medication reconciliation is a formal process designed to improve patient safety by creating the most complete and accurate list possible of all medications a patient is taking, including the name, dosage, frequency, and route. This list is compared against the medications a healthcare provider plans to order or continue. The goal is to identify and resolve discrepancies, which prevents medication errors such as omissions, duplications, incorrect doses, or harmful drug interactions. More than 40% of medication errors are believed to result from inadequate reconciliation during transitions of care.
During Admission and Initial Visits
The first occasion for medication reconciliation happens immediately upon a patient’s arrival at a healthcare facility, such as a hospital or a new primary care clinic. This initial step focuses on creating the Best Possible Medication History (BPMH), which serves as the definitive baseline for all subsequent care. Obtaining the BPMH requires gathering information from multiple sources, including interviewing the patient or their family, reviewing previous medical records, and contacting community pharmacies.
The process is often mandated by regulatory bodies to occur within a specific timeframe, such as within 24 hours of admission, or even earlier for high-risk patients. Incomplete medication histories at admission contribute significantly to prescribing errors. Once the list is compiled, it is formally compared to the new medication orders written by the admitting provider. This ensures all intended changes are documented and discrepancies are resolved before the first hospital dose is given.
During Internal Transfers and Procedural Care
Medication reconciliation is also performed whenever a patient moves between different units or levels of care within the same institution. This transition includes moving from the Emergency Department to an inpatient floor, or from a general medical ward to a more specialized unit like the Intensive Care Unit (ICU). Each internal transfer often involves a change in the prescribing team or a shift in medication protocols, which increases the risk of error.
The reconciliation at this stage ensures that medications appropriate for the previous level of care are either continued, discontinued, or adjusted to suit the patient’s new clinical status. For instance, temporary medications started in the ICU, like certain sedatives, must be formally discontinued or replaced when the patient transfers out. This hand-off prevents the unintentional omission of ongoing treatments or the unnecessary continuation of short-term orders.
Upon Discharge and Care Transition
The final moment for medication reconciliation occurs when a patient is discharged from an acute setting to home or another facility. This step is designed to prevent adverse drug events, which are common within weeks of hospital discharge and frequently lead to readmission. The reconciling clinician compares the medications the patient was taking during the hospital stay with the new medication list they are instructed to take at home.
The discharge reconciliation must clearly document all changes made during the hospital stay, including newly prescribed medications, stopped medications, or dosage adjustments. The patient or caregiver must receive a complete, written list of their post-discharge medications and be educated on how and why to take them. This communication ensures the patient understands the rationale behind the changes, reducing errors and improving adherence in the home setting.
Periodic Review in Outpatient and Long-Term Settings
Medication reconciliation is not limited to acute events; it also occurs routinely in stable care environments, such as outpatient clinics or long-term care facilities. In these settings, reconciliation serves as a proactive safety measure rather than a reaction to a care transition. Clinicians may perform a full reconciliation annually, or at least at specified intervals, to review the patient’s long-term medication use.
This periodic review catches errors that accumulate over time, such as forgotten over-the-counter drugs, herbal supplements, or prescriptions written by specialists unknown to the primary care provider. By comparing the patient’s self-reported list with the official medical record, the process addresses issues of chronic non-adherence or the persistence of old prescriptions. This maintains the accuracy of the medication record.