Medication Reconciliation Process
- Verify patient allergies
- Develop a list of patient’s medical conditions
- Obtain a medication history from the patient, family member(s), and/or caregiver including
- A list of all prescription and non-prescription drugs (OTCs), vitamins, supplements, herbals, and alternative medicines
- Dose, frequency, formulation, and route of administration for each item on the list
- How the patient is actually taking and administering each medication
- Compare this list with at least one of the following:
- Pharmacy dispensing records
- Labels on the patient’s medication bottles
- Records obtained from other providers (e.g. physicians, other pharmacies the patient uses, hospital [for recently discharged patients])
- Obtain patient vaccination history
- Review completed medication list for the following:
- Discrepancies between medication history sources
- Medication adherence issues
- Medication-related problems (see table 1)
- Create and document a plan for addressing items identified during the medication reconciliation
Table 1. Medication-related problems
| Incorrect or missing medication | Medication omission Medication addition Duplicate therapy Medication without indication Indication without medication |
| Potential for adverse effect | History of allergy or intolerance Dose too high Unclear/incorrect instructions Drug-drug or drug-disease state interaction Lack of appropriate monitoring |
| Potential impact on therapeutic efficacy | Dose too low Inappropriate frequency Inappropriate therapy duration Unclear/incorrect route of administration Incorrect dose timing Drug-drug or drug-disease state interaction Drug-food interactions Incomplete drug regimen Incorrect medication administration Inappropriate medication storage |
References
- International Pharmaceutical Federation (FIP). Medicines reconciliation: A toolkit for pharmacists. The Hague: International Pharmaceutical Federation; 2021
- Pharmaceutical Care Network Europe Association. The PCNE Classification V 9.1. https://www.pcne.org/upload/files/417_PCNE_classification_V9-1_final.pdf
- Barnsteiner JH. Medication Reconciliation. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 38. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2648/
