Medication Reconciliation and Comprehensive Medication Review

Adverse Drug Events

It is well known that adverse drug events (ADE) are a leading cause of injury and death in healthcare and that communication problems between settings of care are a significant factor in their occurrence. 67% of patients’ medication histories have one or more errors and up to 46% of medication errors occur during prescription at patient admission or discharge. Erroneous medication histories can lead to discontinuity of therapy, recommencement of discontinued medicines, inappropriate therapy and failure to detect a drug related problem. Up to 27% of hospital prescribing errors are attributable to inaccurate or incomplete medication histories on admission to hospital with the omission of a regular medicine being the most common error. Older patients (≥ 65 years) and those taking multiple medications experience a higher incidence of errors.

The basis for effective medication reconciliation is the development, maintenance and communication of a complete and accurate medication list throughout the continuum of care. Although simple in concept, medication reconciliation is complex to implement reliably.

Medication management in the Geriatric ED consists of a multi-step process.

Best Possible Medication History

The BPMH is the fundamental cornerstone of medication reconciliation. Pharmacists or pharmacy technicians obtain and document the BPMH using more than one source of information and through the involvement of the patient, family or their caregiver. If a current medication list is available in the patient’s record, this is compared with the BPMH and used by physicians to prescribe discharge medication orders. The patient, family member or caregiver are provided with a list of medications the patient should be taking at discharge. Community‐based health care providers (e.g. family doctors, community pharmacies) are often provided with a complete list.

You can see our 10 Practical Tips for a Best Possible Medication History and our BPMH Interview Guide.

Medication Reconciliation

Medication reconciliation has been defined as a process of identifying the most accurate list of all medications a patient is taking and using this list to provide correct medications for patients anywhere within the health care system to ensure accurate and complete medication information transfer at interfaces of care.

Ideally a pharmacist should be involved in gathering or validating the patient’s list of current medications (BPMH) and the comparison of that list with medication orders. When a pharmacist is not available, those tasks should be undertaken by a health care professional (e.g. physician, nurse, therapist, or technologist/technician) who has been trained in collecting a BPMH and reconciling medicines. The culture of the organization with respect to interdisciplinary collaboration and teamwork will significantly influence the effectiveness of the medication reconciliation process.

Steps of medication reconciliation

STEP 1

Obtain a best possible medication history (BPMH): compile a list of medicines the patient is currently taking from interviewing patients and/or carers, referral letters, and other information sources.

STEP 2

Confirm the accuracy of the history: verify using one or more sources. Sources could include local pharmacy, EMR, primary care provider.

STEP 3

Reconcile BPMH with prescribed medicines: compare the BPMH with medicines ordered and resolve discrepancies with prescriber. Document all changes.

STEP 4

Provide accurate medicines information: to receiving clinician, patient and/or carers when care is transferred including list of current medicines and the reasons for changes.

Comprehensive Medication Review (CMR)

CMR is recommended for reducing the frequency of inappropriate polypharmacy and related adverse health outcomes in older patients. The UK NICE defines CMR as “a structured, critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimizing the impact of medicines, minimizing the number of medication-related problems and reducing waste”. In practice, CMRs can vary in their scope and level of detail, ranging from prescription reviews (usually without the patient’s involvement) to full clinical CMRs (with all the available clinical data and with the patient)

Conducting a CMR is important among older populations for several reasons: higher prevalence of polypharmacy and multiple chronic conditions, a higher risk of adverse drug events (ADEs) ,and drug-related admission as an important factor of unplanned hospitalization in this population. In addition, the process of CMR in older patients should take account of drug-drug interactions related to polypharmacy, address the question of possible non-adherence, and consider the presence of geriatric syndromes. In older adults with multiple comorbidities, CMR should undeniably be patient-centered by incorporating patient preferences into treatment decisions via shared decision-making. To support the CMR process and detect PIMs, the clinician can use explicit (criterion-based) tools, implicit (judgement-based) tools. Explicit prescribing criteria for the detection of potentially inappropriate medications (PIMs, i.e. over- and mis-prescribing) and potential prescribing omissions (i.e. under-prescribing) are based on the patient’s drugs and (in some cases) diseases.