It Takes a Village: Medication Reconciliation that Transcends Settings and Professions

Pharmacy Practice in Focus: OncologyAugust 2013
Volume 1
Issue 2

Pharmacists play a critical role in ensuring continuity of medication management as patients are transferred across care settings.

Pharmacists play a critical role in ensuring continuity of medication management as patients are transferred across care settings.

Transitions of care is a hot topic in pharmacy practice and it’s a phrase used often when discussing how to improve the future of health care.

An activity often associated with transitions of care is medication reconciliation. Pharmacists are becoming more involved in medication reconciliation activities, yet the term remains poorly defined in practice.

When a colleague states that she or he performed medication reconciliation on a patient, what does this mean? Did the activity occur as part of a hospital admission, hospital discharge, change in primary care provider, or another activity? What medication list was used as the source of truth for the reconciliation? Was the medication data taken from pharmacy benefit manager claims, a physician’s note, patient and family self-reporting, or a combination of methods?

As medication experts, pharmacists play a critical role in ensuring continuity of medication management as patients are transferred across care settings. This includes designing medication reconciliation programs that clearly outline the steps needed to develop the most comprehensive and accurate medication list possible. The complexity of transitions of care demands that medication reconciliation activities be performed in a manner that transcends professional discipline and practice environment.

Medication Reconciliation Can Fail

A colleague recently shared a story that highlights how medication reconciliation activities can fail when all care settings and disciplines are not coordinated in their efforts. A patient was admitted to an institution with altered mental status and family concern that the patient was being over-medicated. The patient was on approximately 10 medications and had a significant past medical history including schizophrenia, hypertension, gastroesophageal reflux disease, and arthritis.

During the acute care stay, the pharmacist worked with the multidisciplinary team to optimize medication therapy. Metoprolol was discontinued because the patient was bradycardic, the patient’s anti-psychotic regimen was optimized, and the patient was put on a multi-modal pain control regimen to minimize sedative effects.

Unfortunately, the patient was readmitted 28 days following this hospitalization for decreased responsiveness and shortness of breath. Upon admission, the acute care pharmacist realized that the patient was back on many of the medications that had been discontinued during the previous admission, and the dosing changes made during the first admission were not implemented upon discharge.

This time, the acute care pharmacist implemented new steps to help prevent these types of errors from happening again. With the patient’s permission, the pharmacist facilitated disposal of the patient’s home medications that were being discontinued, and the pharmacist developed a discharge medication list and calendar. The pharmacist reviewed the list with the patient and family, paying close attention to educate the family and the patient on the medication changes. The pharmacist also gave the patient a number to call with any questions about the medications following discharge.

Seven days following the second discharge, the patient called the number provided by the pharmacist. The patient reported falling and had complaints of pre-syncope and drowsiness. The pharmacist contacted the patient’s home health nurse and discovered that the updated medication list never made it into the patient’s home. The home health nurse, not having a discharge medication list to use, filled the patient’s pill box using previous dosing instructions.

Despite the pharmacist’s efforts to assist with medication disposal and develop a new list, the patient still was not taking the correct discharge medication regimen and continued to experience adverse effects from the incorrect therapy. The pharmacist coordinated communication with the patient, discharging physician, primary care provider, and home health nurse—finally ensuring that all parties had the correct medication information.

To date, the patient has not been readmitted for more than 9 months.

This example illustrates that even well-developed medication reconciliation activities can fail when there is a lack of communication and information across disciplines and care settings. When performed thoroughly and correctly, medication reconciliation can add value to the care continuum.

Quality Improvement Tactics

How do we ensure the process is of high quality? To start, we need to develop systems that take into account how to communicate changes across care settings and disciplines. We also need to use process and outcome metrics to study models, and use continuous quality improvement tactics to make changes based on the results. How to best measure the impact of transitions of care efforts is not yet known. Partnering with public health professionals and biostatisticians may help in the pursuit of these efforts.

Medication reconciliation is a collaborative and iterative process. Pharmacists play a critical role in developing and leading medication reconciliation programs. The literature has demonstrated that a multi-disciplinary approach to medication reconciliation works well.1 Reviews have also shown that medication reconciliation alone does not solve the problems patients face with transitions of care.2 Rather, medication reconciliation is one piece of a bundle of services that must be applied to optimize medication therapy throughout the continuum of care.

Medication reconciliation doesn’t belong to one profession or one care setting in a vacuum. In many cases, we continue to treat the process in this manner. We must create a system that transcends setting and profession to ensure a patient-centric, high-quality process.

Meghan Davlin Swarthout is the division director of ambulatory and care transitions for the department of pharmacy at the Johns Hopkins Hospital. In her current role, she oversees the clinical services and drug distribution operations for ambulatory clinics and infusion centers. She also maintains a clinical practice in an anticoagulation clinic.Dr. Swarthout earned her doctorate of pharmacy from Ohio Northern University and her MBA in medical services management from Johns Hopkins University. She completed her PGY1/PGY2 in health-system pharmacy administration at the Johns Hopkins Hospital, and she is a board-certified pharmacotherapy specialist.Over the past 3 years, Dr. Swarthout has worked with a multidisciplinary team to develop a transitions of care model designed to reduce preventable readmissions and improve continuity of care. She has presented on the pharmacist’s role in transitions of care for the Institute of Safe Medication Practices, United HealthCare Consortium, the American Society of Health-System Pharmacists, and the Maryland Patient Safety Center. Dr. Swarthout and her team are very proud to be one of the recipients of the ASHP-APhA Medication Management in Care Transitions Best Practices Award.


  • Feldman LS, Costa LL, Feroli ER Jr, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012;5(7):396-401.
  • Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy. Ann Intern Med. 2013;158:397-403.

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