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R E V I E W
Pharmacists and medication reconciliation:
a review of recent literature This article was published in the following Dove Press journal:
Integrated Pharmacy Research and Practice
Eesha Patel 1
Joshua M Pevnick 2,3
Korey A Kennelty 1
1Department of Pharmacy and Practice,
Division of Health Services Research,
University of Iowa, Iowa City, IA, USA; 2Department of Medicine, Division of
General Internal Medicine, Cedars-Sinai
Medical Center, Los Angeles, CA, USA; 3Department of Biomedical Sciences,
Division of Informatics, Cedars-Sinai
Medical Center, Los Angeles, CA, USA
Background: Adverse drug event (ADE) errors are common and costly in health care
systems across the world. Medication reconciliation is a means to decrease these medication-
related injuries and increase quality of care. Research has shown that medication reconcilia-
tion accuracy and efficiency improved when pharmacists are directly involved in the process.
Objective: We review studies examining how pharmacists impact the medication reconci-
liation process and we discuss pharmacists’ future roles during the medication reconciliation
process and then barriers pharmacy staff may face during this critical process.
Methods: A comprehensive literature search from MEDLINE and manual searching of
bibliographies was performed for the time period January 2012 through November 2018.
Conclusion: Although the issue of rising costs and injury due to medication errors in our
health care system are not solvable via medication reconciliation alone, it is the first and
perhaps most critical piece of the medication management puzzle. As such, numerous
organizations have called for pharmacists to expand their roles in the medication reconcilia-
tion process due to their expertise in medication management.
Keywords: medication reconciliation, pharmacists, adverse drug events
Introduction Adverse drug events (ADEs) are a leading cause of injury and death in patients
around the world.1,2 In Europe, it was estimated that nearly 5% of all hospital
admissions were caused by ADEs, and ADEs were responsible for 197,000 deaths
annually.3 In the US, it was estimated that ADEs caused approximately 1.3 million
emergency department (ED) visits and 350,000 hospitalizations each year.4
According to the 2007 Institute of Medicine (IOM), seminal report on Preventing
Medication Errors: Quality Chasm Series, ADEs cost the US health system approxi-
mately $3.5 billion dollars per year.1,5 Previous research has shown that majority of
ADEs are preventable and that medication reconciliation is an effective means to
decrease these medication-related injuries.6–9 In fact, numerous organizations around
the world including The Joint Commission (TJC) recognize medication reconcilia-
tion as a critical component to improve medication safety.2,5 Pharmacists and phar-
macy staff are well positioned to provide patient-centered medication care including
reconciling medications; however, the medication reconciliation process has proven
to be difficult to implement across the health care continuum.10
Medication reconciliation is a robust process intended to identify and resolve
medication discrepancies before they lead to costly and devastating outcomes.
Definitions of medication reconciliation have varied across the literature,11 but the
Correspondence: Korey A Kennelty PHAR S513, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA Tel +1 319 335 8862 Fax +1 319 353 5646 Email [email protected]
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http://doi.org/10.2147/IPRP.S169727
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most basic definition of a medication reconciliation is the
process of creating the most accurate list of what the patient
is taking. The Joint Commission (TJC) has proposed five
main steps to reconcile medications including: 1) develop
a list of what the patient is taking; 2) develop a list of
medications that were prescribed; 3) compare medications
on the two medication lists; 4) make clinical decisions based
on the comparison; and 5) communicate the new medication
list to the patient, caregivers, and providers.5 Medication
reconciliation is a critical process in both inpatient and out-
patient settings and should involve multiple health care
members across settings. A medication reconciliation should
be performed when patients transition between health care
settings or anytime a medication is changed or discontinued.
A goal of medication reconciliation is to create an updated
list of medications that is maintained and guides therapy for
the patient.10,13–16
Numerous studies have been published over the past
two decades that have examined pharmacists’ role during
the medication reconciliation process.12 However, many of
these studies were small and poorly designed. We discuss
larger, recently published studies and reviews that have
reported clinical and economic outcomes of pharmacist
impact in the medication reconciliation process, the future
roles pharmacists have in the medication reconciliation
process, and barriers pharmacy staff may face reconciling
medications.
Methods To perform this review, we targeted articles that were specific
to medication reconciliation and inclusion of pharmacy team
members in outpatient or inpatient settings. We did not limit
studiesfrom the United States. Studiesnot written in English or
published as a conference abstract were excluded from the
review.
Two reviewers (EP and KK) conducted a comprehensive
literature search from MEDLINE limiting the search
January 2012 through November 2018. Search terms
included: medication reconciliation OR medication reconci-
liations OR medication history OR medication histories OR
medication discrepancy OR medication discrepancies AND
pharmacy OR pharmacist. The two reviewers also manually
searched bibliographies of selected studies.
Both reviewers screened the titles and abstracts for
potential studies. One reviewer retrieved the full-text arti-
cles potentially relevant articles, and then both reviewers
agreed before the study was included in the review. If there
was a disagreement between the 2 reviewers, a third
reviewer (JP) reviewed the article and decided whether
the study should be included in the review. One reviewer
(EP) abstracted the following information from all poten-
tially relevant articles using a standardized data abstraction
form: 1) study objectives, 2) keywords, 3) methods, and 4)
outcomes. The 2 reviewers subsequently examined and
confirmed the data abstracted within the form.
Review of studies published since 2012 Our search yielded 904 articles in MEDLINE and 14 articles
by the manual process. However, the authors selected the
studies below to be particularly noteworthy with advancing
knowledge of medication reconciliation and utilization of the
pharmacy team.
Pharmacist impact on medication
reconciliation during care transitions Multiple studies have shown the positive impact pharmacists
have when integrated into the medication reconciliation pro-
cess. Pharmacists often served as the medication therapy
experts on the health care team and were involved in impacting
patient outcomes particularly when a patient transitions from
one health care setting to another.17,18 In a retrospective com-
parison and quality improvement analysis using integrated
health care records from Group Health Cooperative in
Washington State, an evaluation was conducted where patients
with a higher risk for hospital readmission were eligible for
inclusion in the study. Patients either received a multifaceted
intervention including a medication reconciliation (n=243) or
usual care (n=251). Intervention patients received a phone call
from the pharmacist within 3 to 7 days of hospital discharge
during which the pharmacist completed a comprehensive med-
ication therapy assessment to identify any medication-related
problems and then performed a medication reconciliation.
During these phone calls, the pharmacist also addressed patient
concerns that arose after their recent hospital discharge. In the
usual care group, this pharmacist intervention was not
included. The main outcomes measured were readmission
rates (7, 14, and 30 days post discharge) and any financial
benefit of the intervention. It was found that intervention
patients had decreased readmission rates, with statistical sig-
nificance on 7 days: 0.8% vs 4% (P=0.01) and 14 days: 5% vs
9% (P=0.04). The extrapolated financial impact of the phar-
macist-led intervention was calculated to be $1,518,600 in
annual net cost savings as a result of preventing hospital
readmissions.19
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Ravn-Nielsen et al20 reported results on whether
a multifaceted pharmacist intervention reduced hospital read-
mission and ED visits. This randomized controlled trial
included 1,467 patients who were randomized to receive
either usual care, the basic intervention, or an extended
intervention. In addition to medication reconciliation,
patients in the basic intervention group received a patient-
centered medication review by pharmacists at hospital
admission and documented proposed changes in the electro-
nic medical record for physician review when available.
A medication review included pharmacists evaluating the
patient’s medication regimen for any gaps in therapy.
Patients in the extended intervention group received
a medication review but also a comprehensive medication
reconciliation at discharge that included motivational inter-
viewing. Primary care providers, patient’s community phar-
macy, nursing homes, and caregivers were also contacted
with any medication-related issues at discharge. Patients in
the extended intervention group were also followed up via
telephone postdischarge. It was found that the extended
intervention had a statistically significant effect on the num-
ber of patients who experienced a readmission within 30 days
compared to usual care (HR, 0.62; 95% CI, 0.46–0.84) or
within 180 days (HR, 0.75; 95% CI, 0.62–0.90). Further, this
effect was also seen in the number of patients who had
a composite of readmissions or ED visits within 180 days
after inclusion (HR, 0.77; 95% CI, 0.64–0.93). The authors
concluded that pharmacists may play an important role in
decreasing hospital readmissions.20
In a study by The Permanente Medical Group, data from
18 Kaiser Permanente hospitals were collected and 30-day
all-cause readmission factors were studied. A total of 537
readmissions were analyzed, in which 250 (47%) readmis-
sions were assessed as potentially preventable with medica-
tion management as one of the main focus areas for
improvement.14 The authors suggested that an area where
pharmacists can make an impact is in the ED. Pharmacists
would have the ability to perform medication reconciliation
services on patients who may be admitted or discharged, and
subsequently provide medication management services to
increase the overall quality of care provided to hospitalized
patients.
A study conducted at Northwestern Memorial Hospital
reported the impact of a pharmacist-led medication interven-
tion, including medication reconciliation at admission and
discharge, on 30-day patient readmission rates and ADEs.21
Patients were randomly assigned to receive either usual care or
the intervention. A total of 278 patients were included in the
final analysis. Eligibility consisted of patients who were dis-
charged home on greater than three scheduled prescription
medication or were taking at least one high-risk medication.
Patients in the usual care received a medication reconciliation
performed by the pharmacist and then medication counseling
provided by the physician or nursing staff at discharge. The
intervention group also receive a personalized medication plan
created by pharmacist at discharge, and medication discrepan-
cies were addressed before the patient left the facility.
Medication counseling was then performed, and follow-up
phone calls were scheduled at days 3, 14, and 30 days post-
discharge. Authors reported a total of 380 medication discre-
pancies (46.2%) in the intervention group, compared to 205
(19.9%) from the usual care group (P<0.0001).26 In terms of
hospital readmission, 55 patients (39%) in the usual care group
were readmitted or had an ED visit within the 30 days post-
discharge period compared to the 34 (24.8%) patients from the
intervention arm (P=0.001). This study showed that pharma-
cists were key to rectifying medication discrepancies as well as
optimizing the patient’s medication regimen postdischarge.21
In the final study discussed in this section, the impact of
the pharmacist during hospital admission and discharge was
measured along with a cost analysis of the intervention.22
Patients over the age of 18 who received care from either
medical or surgical units were included in the study for
a 7-week period. The primary outcome measure was the
number and severity of medication errors found by the
pharmacist per patient per service. Secondary outcome
measures were a comparison of the 7-day and 30-day read-
mission rates to a historical cohort of patients admitted and
discharged from the same two units from July and
August 2013. During the study, 67 patients were assessed
for their admission and discharge medication lists. A total
of 84 medication errors were identified with a mean of
1.25±2.04 errors per patient. Six percent of these errors
(5/84) were classified as serious; 75% (63/84) and 19%
(16/84) were considered to be significant and minor, respec-
tively. The total cost of avoidance was estimated at $42,400,
and if the results were extrapolated to the entire adult
population in the facility (the study estimated a total of
26,000 adult discharges annually), the cost of avoidance
was estimated to be $16,415,000 due to a hypothetical
reduction in medical errors.22
These studies highlighted the impact of a pharmacist by
preventing and reducing medication errors through medica-
tion reconciliation and related interventions. As underscored
in these studies, medication reconciliation is a patient care
service that requires ongoing communication between the
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patient, pharmacist, and provider. This allows the team to
work together to provide quality care and ensure that preven-
table errors are avoided and in a way that has potential for
reducing costs.
Medication reconciliation is necessary but
not sufficient for improving outcomes Historically, there has been little coordination across health
care settings for patients living with chronic conditions.23 This
fragmentation jeopardizes patient safety and increases patient
risk of costly rehospitalizations.23–25 The Chronic Care Model
(CCM) addresses the growing needs of the current health care
system by offering an evidence-based framework for deliver-
ing comprehensive care management.23–25 The CCM is an
organizational approach to providing care to patients living
with multiple chronic conditions in the outpatient setting,
including the consistency of medications between health care
settings. It highlights the importance of a team-based approach
in collaboration with the patient with the idea that the decision-
maker is not solely the primary care provider. The overarching
goal of the CCM is to improve health care quality and acces-
sibility and increase patient awareness of health, thus improv-
ing health outcomes. The CCM identifies the necessary
components that must be present in order to to promote high-
quality chronic disease management: the community; the
health system; self-management support; delivery system
design; decision support, and clinical information systems.
Each component may be modified to facilitate patient-
centered chronic disease management. The CCM has been
widely used as a guide to redesign the management of many
chronic diseases including diabetes and hypertension.25–27
Medication reconciliation is part of a process, which is
necessary but not sufficient for improving overall outcomes.
It is an important component of the patient-centered care
process, in which pharmacists have a role to ensure positive
outcomes. However, multiple approaches are needed to pro-
vide high-quality care. In a study evaluating the effectiveness
of a large-scale readmission reduction program funded by the
Center for Medicare & Medicaid Services (CMS), the overall
Medicare fee-for-service (FFS) readmissions were examined
for 10,621 patients.28 The quasi-experimental evaluation found
that the readmission reduction effort including personalized
transitional care, including education, medication reconcilia-
tion, follow-up telephone calls, and linkage to community
resources reduced readmissions by 9.3% among a population
targeted by CMS. Patients did not receive all intervention, and
patients received a mean of 4.3 interventions (range 0–16),
suggesting that decreasing readmissions should be
a multifactorial effort among health systems.28
Pharmacists have key roles in medication
reconciliation Research has shown that medication reconciliation accuracy
and efficiency improved when pharmacists are directly
involved in the process. As such, the World Health
Organization (WHO) as well as other several key organiza-
tions have called for pharmacists to perform the medication
reconciliation process due to their expertise in medication
management. For example, the American Society of Health-
System Pharmacists (ASHP) recommends that pharmacists
must have key roles in the medication reconciliation process
by:29,30 1) designing and managing patient-centered medica-
tion reconciliation processes; 2) providing education to
patients and their providers about the benefits and limitations
of medication reconciliation processes; and 3) advocating for
patients when they transition from one healthcare setting to
another. Beyond serving in the direct medication reconcilia-
tion activities, pharmacists should oversee the development
of policies to integrate medication reconciliation practices
into the culture and everyday workflow of the health care
system. Other activities such as continuous quality improve-
ment, training, ensuring ongoing competency, and therapeu-
tic expertise for information systems development may also
be placed under the pharmacy purview.30
Health systems are frequently resource constrained, so
streamlining and dividing responsibilities during the medica-
tion reconciliation process is necessary for sustainment of
practices. In many health care settings, pharmacy teams con-
sisting of pharmacists, pharmacy technicians, pharmacy resi-
dents, interns (eg, pharmacy students), and clerks may be
tasked with the medication reconciliation process. Previous
research has shown that pharmacy technicians and pharmacy
students have been successfully involved with medication
reconciliation activities. Champion et al31 conducted a review
of 32 studies to examine how pharmacy students and techni-
cians have been utilized in medication reconciliation processes
in an effort to evaluate expanded roles for pharmacy students
and technicians. The authors reported that pharmacy students
and technicians with proper training were able to obtain med-
ication histories, identify discrepancies, and take appropriate
action to correct these discrepancies. Cost savings to health
systems were also reported in select studies when pharmacy
technicians or students replaced pharmacists or nurses during
part of the medication reconciliation process.31 In another
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study, Gortney et al32 reported on outcomes of medication
histories collected by trained student pharmacists measured
by the accuracy and completeness of the subsequent discharge
medication list compared to patients in the control group.
A total of 215 patient medication histories were obtained by
17 pharmacy student interns over a 12-month period. The
student pharmacists made a total of 76 interventions to inpa-
tient medication regimens, which affected a total of 25% of
patients. Pevnick et al33 reported the results of their three-arm
randomized controlled trial of 306 hospitalized patients. The
first arm was usual care; the second and third arm included the
pharmacist or pharmacy technician (respectively) obtaining
and reconciling medication information from multiple sources
prior to patient admission. Errors in the admission medication
history were reduced by over 80% when a pharmacist or
technician was involved during the medication reconciliation
process at hospital admission.33
The role of student pharmacist in the institutional setting is
to work along with and learn from the pharmacist. An excellent
hands-on experience a student pharmacist can receive is
through the medication history process where students are
presented with the opportunity to learn and develop skills
such as assessing the ADE for risk and then appropriately
triaging the medication-related issue to the appropriate provi-
der. The medication history process allows for student phar-
macists to enhance their communication skills and build
confidence in their ability to translate their didactic knowledge
into practice. The process allows a student to reinforce profes-
sional curriculum, potentially decrease ADEs due to inaccurate
medication histories, and allows the student to grow under the
supervision of a trained clinical pharmacist.
Challenges (or barriers) to medication
reconciliation Some hospitals have limited resources and may find difficulty
with the implementation of the medication reconciliation
process.34 This is pronounced in smaller institutions, critical
access hospitals, and those serving safety net populations.
These institutions may frequently lack pharmacy team mem-
bers to conduct medication reconciliation or perhaps in some
countries pharmacists are not authorized to perform this pro-
cess. As such, the medication reconciliation process may be
designated to another team member (eg, physicians, nurses,
and nursing assistants). Previous studies have reported the
differences in outcomes when medication reconciliation was
performed by a pharmacist or pharmacy technician compared
to other health care team members.35–38 For example, Kramer
et al reported that nurses had significantly higher discrepancy
rates per medication (0.59) compared with pharmacy techni-
cians (0.36) and pharmacists (0.16) (P<0.001). Pharmacists, on
the other hand, corrected significantly more discrepancies per
participant than nurses (6.39 vs 0.48; P<0.001).37
Issues arise when team members who perform the med-
ication reconciliation process may not have a working
knowledge of different medications and how the medications
translate to different disease states. Thus, it is important for
team members to receive appropriate training on performing
a medication reconciliation, particularly when taking
a medication history. The use of standardized tools to stan-
dardize the medication reconciliation process has produced
positive results in admission medication lists obtained by
nursing students in a community hospital.39 One study
showed the accuracy of medication lists during the medica-
tion reconciliation process improved significantly with stu-
dent nurses who used the standardized tool and received
appropriate training versus those who did not (87% versus
74%, P=0.010).39 Fortunately, there are publicly available
resources to assist health care professionals with implement-
ing medication reconciliation practices. For example, the
MARQUIS Implementation Manual: A Guide for
Medication Reconciliation Quality Improvement outlines
best practices around medication reconciliation practices
and provides enough detail so health systems can adapt
these processes based on their environment.40 The WHO’s
The High5s Project – Standard Operating Protocol for
Medication Reconciliation was released to help provide stan-
dardization of medication reconciliation procedures and
guiding principles for implementing processes in health
care settings.41
The ability to transmit health records from one facility to
another is a current challenge among health systems face.
When a patient is admitted or discharged from the hospital, it
is essential to receive and transmit timely information to out-
side providers. Despite the potential for health information
technology (IT) to increase the quality of care and promote
continuity of care when patients transition from one health care
setting to another, cost related to the infrastructure needed to
share medical records is a major barrier. One study estimated
that the costs for an average five-physician outpatient practice
to implement an electronic health record system would be
$162,000 with $85,500 in maintenance expenses during the
first year alone.42 Community pharmacies often do not have
access to medical records from outside health systems despite
the fact that patients often fill their prescription medications at
community pharmacies while residing in the outpatient
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setting.43 Assistance with the implementation of electronic
health records and the subsequent promotion of health infor-
mation exchange is needed to allow pharmacists and providers
to improve the consistency of health care information across
multiple electronic platforms.44
Conclusion In this review, we highlighted several exemplar studies exam-
ining the potential that pharmacists and pharmacy staff have to
positively impact the medication reconciliation process, and
how this translates to the overall care process including
decreasing overall system costs. These studies demonstrate
that the medication reconciliation process should be a team-
based effort requiring the expertise and time of multiple health
care professionals. With ongoing collaboration from all mem-
bers of the health care team, preventable medication errors can
be decreased. Although the issue of rising costs and injury due
to medication errors in our healthcare system are not solvable
via medication reconciliation alone, it is the first and perhaps
most critical piece of the medication management puzzle.
Acknowledgments This research was supported by the National Institute on
Aging, United States of the National Institutes of Health,
United States under awards K23AG049181 (JMP),
R01AG058911 (JMP, KAK), R01HL139918 (KAK),
R18HL116259 (KAK), R01HL116311 (KAK), and
U01CE002961 (KAK) . The content is solely the responsibility
of the authors and does not necessarily represent the official
views of the National Institutes of Health or the Centers for
Disease Control and Prevention.
Disclosure JMP reports grants from National Institutes of Health -
National Institute on Aging, during the conduct of the study;
grants from American Society of Health-System Pharmacists
Research and Education Foundation, outside the submitted
work; KAK reports grants from National Institutes of Health
– National Institute on Aging as well as the National Heart,
Lung and Blood Institute, and the Centers for Disease Control
and Prevention, during the conduct of the study. The authors
report no other conflicts of interest in this work.
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