Pt. Safety

Medication Reconciliation

A shared patient safety problem worldwide is the lack of accurate and complete information about patients’ medicines when their care is transferred between healthcare settings.

In up to two-thirds of patients there are variances between the medicines they take at home and the medicines ordered on admission to hospital.

It has been estimated that around half of the medication errors that happen in hospital occur on admission or discharge from a clinical unit or hospital. Around 30% of these errors have the potential to cause patient harm. 

Patients may receive new medications or even have changes made to their existing medications at times of transitions in care (upon hospital admission, a transfer from one unit to another during hospitalization, or discharge from the hospital to home or another facility).

Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking  (including drug name, dosage, frequency, and route); and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital. 

According to the Institute of Medicine’s Preventing Medication Errors report, the average hospitalized patient is subject to at least one medication error per day. This confirms previous research findings that medication errors represent the most common patient safety error.

More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients. Of these errors, about 20 percent are believed to result in harm. 

Many of these errors would be averted if medication reconciliation processes were in place.

Simply speaking I understand medication reconciliation as comparing the medications that a patient is actually taking with the medication that a patient is prescribed.

Medication reconciliation is a three-step process: 

  1. Verification: collecting an accurate medication history
  2. Clarification: ensuring that the medications and doses are appropriate
  3. Reconciliation: documenting every single change and making sure it “squares” with all the other medication information.


  • Tam V, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173:510-5.
  • Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual 2005;20:95-8.
  • Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006;15:122-6.
  • Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424-9.
  • National Institute for Health and Clinical Excellence and National Patient Safety Agency. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. London: NHS; 2007.
  • Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press; 2006.

  • Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307 11. [PubMed]

  • Rozich JD, Howard RJ, Justeson JM, et al. Patient safety standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf. 2004;30(1):5–14. [PubMed]

  • Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004;61:1689–95. [PubMed]

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Dr. Khalid Abulmajd

Healthcare Quality Consultant

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