As defined by the JCAHO, 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. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care.
Medication Reconciliation Process
The medication reconciliation process comprises five steps:
This means that there are two parts to address medication reconciliation:
- Develop a list of current medications;
- Develop a list of medications to be prescribed;
- Compare the medications on the two lists
- Make clinical decisions based on the comparison
- Communicate the new list to appropriate caregivers and to the patient."
Part A) Clinician/pharmacist reviews medication profile with the patient to assure it is correct and up-to-date.
- Discontinue all non-active medications
- Renew all expired medications
- If the patient already has these medications, the pharmacist places them on hold
- Prescribe new medications not on the medication profile including OTC, herbal, and traditional medications
- All prescriptions will contain the indication for prescribing (to address health literacy)
Part B) Patients will receive a copy of their medication profile using the Patient Wellness Handout or other printed report.
- The medication profile will contain medications with the status of active, hold, or returned to stock.
- Medications that are expired and not current therapy and discontinued should not appear on the profile
- Consider printing a copy of the Patient Wellness Handout for the patient containing their medication profile.
- The medication profile is to be reviewed with the patient.
- Document the medication reconciliation process using the patient education code: M-MR (see Patient Education Protocol for Medication Reconciliation). [DOC-62KB]