Evidence Table

Medication Reconciliation

StudyAimDesign & SampleSiteOutcome
Bates 199934Assess strength of patient risk factors for adverse drug events (ADEs)Nested case control 4,108 admissions11 medical and surgical units in 2 tertiary care hospitalsAdverse drug events more frequent in sicker patients with longer hospital stay. Few risk factors emerged when controlling for level of care and pre-event length of stay. Prevention strategies should focus on improving medications systems.
Bayley 20057Enhance understanding of how patient handoffs are related to risk of adverse medical events before and after implementation of an information technology solutionInformant interviewsOne primary care practice and four inpatient facilities (one academic medical center and three community hospitals)Based on thematic analysis of qualitative data, identified information barriers due to work processes, role definitions, and individual discretion which can assist in designing effective technology solutions.
Bedell 200011Examine frequency of discrepancy between medications prescribed and those taken and associated causal factors. Compare medication containers and reported use of medication with medical recordsDescriptive design 312 medical records in ambulatory setting5 cardiology and 3 internal medicine practices545 discrepancies among 239 patients (76%)
278 (51%) taking meds not recorded in chart
158 (29%) not taking recorded meds
109 (20%) taking different dosage than in chart.
Predictors of discrepancy: age of pt, number of meds and multiple physicians
Boockvar 200422Identify medication changes during transfer between hospital and nursing home and ADEs caused by these changesDescriptive study of residents of 4 nursing homes admitted to 2 academic hospitals. Nursing home and hospital records reviewed to identify changes in medication regimens between sites. Medications matched and compared regarding dosage, route, and frequency of administration4 nursing homesDuring 122 admissions, the mean numbers of medications altered during transfer from nursing home to hospital and hospital to nursing home were 3.1 and 1.4, respectively (p<.001). Changes in drug use were discontinuations, dose changes and class substitutions. Of 71 bidirectional transfers, ADEs attributable to medication changes occurred during 14 (20%). Overall risk of ADE per drug alteration (n=320) was 4.4% Most medication changes (8/14) implicated in causing ADEs occurred in the hospital, most ADEs (12/14) occurred in the nursing home after nursing home readmission.
Chevalier 200614Measure nurses’ perceptions of patient safety, medication safety and current medication reconciliation practice at transition points in a patient’s hospital stayDescriptive survey of 111 nursing staffThree general medicine unitsInconsistent medication reconciliation completion due to insufficient time and lack of communication among heath care professionals.
DeCarolis 200527Compare usual process of obtaining medication history to systematic reconciliation processComparison of pharmacist obtained medication history to inpatient medical record and computerized outpatient medical profile.1 VA medical center71% of patients had inaccurate computerized profile. Unintended order discrepancies in 58% of patients. Medication reconciliation system reduced unintended order discrepancy to 43%
Ernst 20019Assess accuracy of data in the EMR and document frequency and types of discrepancies that occurred.Compared prescription renewal requests with electronic medical record data. 950 prescription- renewal requests for 134 medications over 3 month period.Family Medicine Outpatient ClinicMedication discrepancies were noted for 250 (26.3%) requests. 58.8% of the discrepancies were for prescriptions patient was taking but that were not ordered in the EMR medication list.
Gleason 20044Identify type, frequency, and severity of medication discrepancies in admission orders.
Assess whether pharmacist obtained admission med histories decreased number of med errors.
Convenience sample compared 204 pharmacist conducted medication histories from patients to medication and allergy history documented in patient charts725 bed tertiary care academic medical center. Direct admissions to 12 adult medical- surgical unitsInterviews took on average 13.4 minutes. Discrepancies in medication histories and admission medication orders identified in more than 50% of patients. 22% could have been harmful if no intervention.
Kramer 200728Establish feasibility of electronic system for pharmacist and RN admission and discharge medication reconciliation and assess effect on patient safety, cost, satisfaction among providers and nursesPre-post electronic reconciliation process283 patients on general medicine unit, 147 in preimplementation phase and 136 in postimplementation phase.Preimplementation RNs identified more incomplete medication orders and dosage changes
Post implementation greater numbers of allergies were identified, pharmacists completed significantly more dosage changes and patients reported higher level of agreement re discharge medication instructions.
Lack of MD participation, 25% did not complete electronic discharge report
Lau 20008Compare medication history in hospital medical record with community pharmacy records prior to admissionProspective observational study of 304 patientsGeneral medical units of 2 acute care hospitals61% of patients had discrepancy from community pharmacy records to inpatient medication history. 26% of prescription medications in use prior to admission were not listed in hospital medical records.
Manley 200312Determine rate of drug record discrepancies in a hemodialysis populationProspective observational study of 63 patientsOutpatient hemodialysis center60% of patients had drug record discrepancies.
Miller 199210Improve family practice office chart documentation of prescribed medications through use of duplicate prescription formsDescriptive study of implementation of duplicate prescription forms
Baseline chart review – 67 charts
Duplicate prescription form: 1 week = 50 charts; 40 months = 60 charts
Ambulatory family practiceBaseline: 51 patients (76%) had prescribed medications with 87% of charts with incomplete or no documentation
1 week: 83% of charts had complete prescription medication documentation
40 Months: 82% of charts had complete prescription medication documentation
Moore 200323Determine prevalence of medical errors from inpatient to outpatient settingDescriptive study of 86 patients inpatient and ambulatory medical records950 bed urban teaching hospital and affiliated primary care practice42% of patients had at least 1 medication continuity error
Nickerson 200518Determine clinical impact on drug therapy problems (DTP) of pharmacist review of discharge medications at dischargeRandomized clinical trial with 6 month followup of 253 patients2 inpatient family practice unitsPharmacist intervened in 481DTP with average per patient of 3.49. Control group retrospective chart review found 56% had DTP
Paquette-Lamontagne 200225Improve accuracy of patient profile information in community pharmacies with use of discharge prescription formsQuasi experimental intervention with 89 patientsMedical units in 3 teaching hospitals82% of medication profiles in experimental group were complete as compared to 40% in control group
Pronovost 200320Reduce medication errors with a reconciliation process using paper form at discharge fro surgical ICUIntervention using paper medication discharge form for ICU dischargesSurgical ICUAt baseline 94% of discharge orders were changed due to discrepancies. At Week 24 discharge error rate was 0
Pronovost 200421Reduce medication errors with a reconciliation process using an electronic form at discharge from surgical ICUIntervention using electronic medication discharge form for ICU discharges1,455 patients in surgical ICU over 1 year period21% of patients required medication order change. 6% due to allergy discrepancy
Rozich 200115

Rozich 20043
Reduce medication discrepancies at health care transition points through the implementation of a medication reconciliation process on admission, during transfer and at discharge from the hospitalDescriptive study of implementation of medication reconciliation processAcute care inpatient units
Baseline 20 charts per week for 6 weeks the ongoing chart review
Baseline medication discrepancy rate 213 per 100 admissions. 7 month post introduction of reconciliation process rate was 42 per 100 admissions.
Vira 200613Describe potential impact of medication reconciliation process to identify and rectify errors at time of hospital admission and discharge60 randomly selected patients. Compared admission medication orders with patient medication vials and interviews with patients, caregivers and outpatient health care providers. At discharge, pre-admission and in patient medications compared with discharge orders and written instructions.Inpatient community hospital60% of patients had minimum of 1 unintended variance with 18% having minimum of 1 clinically important variance. None were detected outside of reconciliation process
Wagner 199626Assess correspondence between medications the patient taking and documentation in EMRDescriptive comparison of patient report and chart review study of 312 medical recordsOutpatient geriatric centerMean number of medications per patient: 5.67
Mean number of medications listed in EMR: 4.69
Missing medication recording attributed to patient misreport (36%) and MD/NP failure to note medication changes in EMR (26%)
Whittington 200430Reduce percentage of admission ADEs caused by errors in reconciliation through use of admission reconciliation form as hospital medication record and discharge prescription formDescriptive study of implementation of medication reconciliation process Number of patients enrolled not reported4 hospitalsChange from 45% to 95% accuracy of medication list on implementation of reconciliation process.
Winterstein 200635Evaluate medication safety infrastructure of critical- access hospitals in FloridaQualitative assessments using self-administered survey and site visits of 7 hospitals.7 critical access hospitals in FloridaCharacteristics targeted for quality improvement included medication reconciliation. Admission medications infrequently reviewed, and readmissions were associated with higher prevalence of medication errors

From: Chapter 38, Medication Reconciliation

Cover of Patient Safety and Quality
Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
Hughes RG, editor.

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