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Research has demonstrated that preventable adverse drug events are associated with as many as one in five patient injuries or deaths. Inaccurate communication of medical information at transitions of care is responsible for up to half of all medication errors in hospitals. The inadvertent omission of a preadmission medication or the failure to order a drug upon discharge can have harmful outcomes. An accurate and reliable process for medication reconciliation at all transitions of care is key to preventing adverse drug events and avoiding patient harm.

Medication reconciliation is described by the Centers for Medicare & Medicaid Services (CMS) as the process of identifying the most accurate list of all medications the patient is taking by comparing the medical record to an external list of medications obtained from the patient, hospital, or provider. A hospital must have a formal process for healthcare providers and pharmacists to use to gather a complete and accurate list of a patient’s prescribed and home medications. By identifying any discrepancies in drug regimens at distinct levels of care, care settings, or points in time, the hospital helps to ensure correct prescribing decisions by providers and prevention of medication errors. The goal of medication reconciliation is to provide the patient with correct medications at all transitional points within the hospital.

This month, the Accreditation Commission for Health Care (ACHC) Acute Care Hospital (ACH) program takes a look at ACHC Accreditation Standards regarding medication reconciliation.

Standard 25.02.03: Medication Reconciliation

Patients are often transferred from one unit or care setting to another during their hospital stay. Transitions of care occur anytime a patient is moved from one setting or level of care to a different one. Medication reconciliation should take place at each key transitional point of care during a patient’s hospital stay. This standard identifies three key transition points where errors with writing medication orders tend to occur:

• Upon admission to the hospital.
• Upon transfer to a new unit, service, or practitioner.
• At the time of discharge.

On Admission

When a patient is admitted to a hospital, whether through the emergency department, through surgical services, or as a direct admission from a provider, it is imperative that clinicians perform an initial medication reconciliation process to review and validate the patient’s list of pre-admission medications. This list should include the name, dosage, frequency, route, and indication for use. It must include all prescribed and regularly taken over-the-counter drugs, herbals, vitamins, and homeopathic and nutritional supplements.

It is important to validate the list of medications with the patient and/or family member, not only for accuracy of the list but also to confirm if the patient is actually taking the medications as prescribed. The process enables the admitting physician or practitioner to make accurate decisions as to whether medications should be continued, changed, or discontinued while the patient is in the hospital. Patients and subsequent health care providers need to be informed of these changes. Admission orders should be considered a modification of the patient’s medication regimen.

The hospital policy should define the medication reconciliation process implemented, responsible individuals, and the timeframe for completing the initial reconciliation process. ACHC Standard 25.02.03 states the initial reconciliation process must take place within 24 hours of hospital admission.

It is important to remember it is not acceptable for a practitioner to document in a patient order or note any of the following:

• Resume previous orders.
• Resume preoperative orders.
• Resume all home medications.

Transfer to New Unit, Service, or Practitioner

When a patient is being transferred to another unit or service, a current list of the patient’s medications must accompany the patient. This is another key transitional point when medication reconciliation must take place. This process should be standardized to ensure a comprehensive reconciliation occurs to reduce potentially harmful medication errors. Discrepancies between the list of medications from the previous unit and those ordered following transfer must be discussed and reconciled with the prescriber.

One example of a key transition point is when a patient is being transferred to the operating room for a surgical procedure. The list of the patient’s current medications must be available on arrival to the pre-operative and/or OR area. Surgery is a new service or level of care, and this transition point is considered a high-risk situation for potential medication errors. Hospital policy should define the medication reconciliation process to be used and whether medications are discontinued or put “on hold” when a patient goes to surgery.

Post-operatively, before the patient returns to the inpatient unit, the medication reconciliation must be completed again. Discrepancies between the list of medications from the previous unit, those ordered in OR/PACU, and those to be continued postoperatively should be discussed and reconciled with the prescriber. Medications administered in surgical services areas may not be safe if given outside of these areas. IV narcotics and anesthesia medications could result in serious harm or death if mistakenly administered to a patient. Many organizations have a process that automatically discontinues these high-risk medications upon transfer of the patient back to an inpatient unit after recovery. The medication reconciliation process would ensure all medications are evaluated and resumed or discontinued as appropriate by the provider to prevent medication errors.

There are numerous other care transitions that require medication reconciliation, such as:

• Emergency department to inpatient unit: A complete list of current medications should be documented for all ED patients.
• Critical care units to step-down or medical/surgical unit.
• To and from any procedural areas, such as cardiac catheterization, endoscopy, and interventional radiology.

Discharge from Hospital

Discharge of the patient from the hospital is another key transitional point and an essential time for accurate medication reconciliation. As part of discharge planning, a reconciliation process must take place to ensure all appropriate medications, including preadmission medications, are continued following discharge. In anticipation of discharge, the list of preadmission medications should be compared against the current medication administration record. Lack of a medication reconciliation at discharge can result in unexplained medication discrepancies between pre-admission and post-discharge medication lists, a situation that often is found to be a contributing factor in hospital readmissions. The patient and/or family should be informed of medications that will be discontinued or changed upon discharge.

At the time of discharge, a written copy of the final medication list must be provided to:

• The patient and/or family, as appropriate.
• The next level of care, such as a home health agency, skilled nursing facility, or transfer to another hospital.

Ambulatory Services

A current list of medications must be reviewed and validated for ambulatory care patients. The complete list should be updated when medications are added or discontinued for all outpatient services where medications will be administered, such as:

• Ambulatory surgery.
• Radiology or other testing that requires medications or IV contrast may be given.

In outpatient services where no medication will be administered, it is best practice to obtain a current list of medications, but doing so is not required.

Tips for Compliance

• The Acute Care Hospital policy should clearly define the processes for various settings and transitions of care.
• While medication reconciliation has traditionally been a manual, paper-based process, the implementation of the Electronic Health Record (EHR) and other health IT interoperability systems has automated some aspects of medication reconciliation.
• Facilitation of electronic medication reconciliation processes improves communication regarding medications for patients, providers, and hospitals.
• The Acute Care Hospital must ensure a process is in place to measure the effectiveness of the hospital’s medication reconciliation practices in reducing adverse drug events.

Medication reconciliation is an important process to prevent adverse drug events and patient harm. It also plays a vital role in providing high-quality patient care. Hospitals and other health care institutions have recognized the importance of accurate medication reconciliation, and this has led to organizational efforts to improve awareness and accuracy of this process.

Here to Help

To access the most recent ACHC Accreditation Standards Manual, please contact your Account Advisor or email us at customerservice@achc.org.

Some content presented in “Did You Know?” may consist of timely or topical articles deemed to be of interest to the provider community. These are presented for informational purposes as a service to our readers. The views, opinions, and positions expressed by the authors are theirs alone and do not necessarily reflect the views, opinions, or positions of ACHC, its related entities, or any employee thereof.