Pharmacy-Led Medication Reconciliation Is Best Practice

Pharmacy Practice in Focus: Health SystemsSeptember 2023
Volume 12
Issue 5

The TJC and IHI advocate for medication reconciliation at all transitions of care.

Medication reconciliation involves the comparison of a patient’s home medication list with medications ordered by the prescriber at each transition of care.1,2 The goal of reconciliation is to identify and resolve discrepancies between the two, such as medication omissions, duplications, and documentation errors, and to ensure that any changes are communicated among clinicians.2,3 Both The Joint Commission (TJC) and the Institute for Healthcare Improvement (IHI) advocate for the completion of medication reconciliation at all transitions of care. As the medical literature indicates, including these activities as part of routine patient management can prevent adverse events (AEs), potentially impacting patient outcomes.1,3 Pharmacy involvement in this process, including obtaining medication histories and completing admission and discharge reconciliation, is an important consideration when designing best practices.

Image credit: Joel bubble ben -

Image credit: Joel bubble ben -

Findings From the Medication Literature Support Pharmacy Involvement

An abundance of medical literature demonstrates that pharmacy participation in the medication reconciliation process is a cost-effective approach to optimizing patient care by preventing medication errors during transitions, facilitating communications among practitioners, allowing providers more time for other patient care tasks, and reducing 30-day readmissions.4-6 Medication reconciliation is a multistep process and includes, at minimum, obtaining a medication history, admission reconciliation, and discharge reconciliation.

The first step is to obtain a thorough and accurate list of the patient’s home medications, including prescription, OTC, and complementary and alternative medications. If a patient is transferred from an outside facility, the medication list may include medications received at outside hospitals or during the transfer process. Data cited by the World Health Organization (WHO) indicate that 67% of medication histories contain at least 1 error, creating discrepancies between what is ordered for the patient in the hospital and how the medication is taken at home.7 Twenty-seven percent of prescribing errors can be attributed to inaccurate or incomplete home medication lists.7

Marshall et al recently published an observational, retrospective review examining the impact of a pharmacy-driven medication history program on patient outcomes. Results demonstrated a significant reduction in patient length of stay and in-hospital mortality with fewer medication-related AEs. An accurate patient home medication list not only reduces prescribing errors but also facilitates more efficient admission and discharge reconciliation processes.4

Admission reconciliation is the next step in the process and involves comparing the list of a patient’s home medications to the medication orders placed by a prescriber. Several systematic reviews and studies have been conducted investigating patient outcomes with pharmacy-led admission reconciliation in a variety of patient care settings. Choi et al conducted a systematic review and meta-analysis in 2019, finding that pharmacy involvement in the admission reconciliation process resulted in significant reductions in both mean discrepancies per patient and potential AEs.8 These findings were particularly noted in medically complex patients (ie, > 3 comorbidities and > 4 medications) and in those potential AEs related to severe or life-threatening events.8

Pediatric patients represent a particularly high-risk patient population, with up to 37% of hospitalized children experiencing errors with medication prescribing and 67% having discrepancies in their medication histories.9 Hovey et al conducted a prospective observational cohort examining pharmacist-managed admission reconciliation, demonstrating that 22% of pharmacy interventions were found to be clinically relevant, with 8 interventions determined to have likely prevented harm or death, over a 90-day time period.9 Investigators were also able to quantify a potential annual cost savings of $186,986.60 resulting from pharmacy participation in the admission reconciliation process.9

Discharge reconciliation is the final step in the process and includes a review of a patient’s home medication list, medication administration record, and medical notes within the electronic health record for regimen changes during the hospitalization, culminating in the generation of a discharge medication list. Published data have shown that up to 40% of patients have discrepancies in their medication lists at discharge, which poses a greater risk to patients than errors during the admission process as they are transitioning to the home environment without ongoing monitoring.10 Professional organizations recommend that best practice includes the involvement of pharmacy in multidisciplinary teams managing transitions of care, as evidence has shown that pharmacy involvement reduces postdischarge emergency department visits and readmissions and is more cost-effective than other interventions.5,10

Rodrigues et al investigated the impact of pharmacy-supported transitions of care activities on 30-day readmissions.5 The authors found that pharmacy involvement in transitions-of-care activities resulted in a meaningful impact on 30-day readmissions, which was further enhanced when patient-centered follow-up (eg, phone call, home visit, clinic visit) was included. No studies had results that favored the usual care group (ie, without pharmacy intervention). Medication reconciliation was the most common intervention, which often included patient counseling.5 Investigators noted that pharmacy personnel are uniquely qualified to provide reconciliation services, resulting in decreases in preventable adverse drug events and improved medication adherence.5

In 2012, the Centers for Medicare & Medicaid Services (CMS) enacted the Hospital Readmissions Reduction Program (HRRP) with a goal of reducing preventable hospital readmissions and promoting value-based care.6 The program penalizes hospitals with higher-than-predicted 30-day readmission rates for specific disease states by reducing their reimbursement rates. In response, hospitals developed transitions-of- care programs to improve patient outcomes and reduce readmissions, with many recognizing the role of pharmacists as medication management specialists who could optimize medication regimens, prevent medication-related problems, and facilitate safe transitions to home.6

Harris et al performed a 123-article systematic review evaluating the impact of pharmacy-led reconciliation services that were developed by hospitals in response to the HRRP. Just over 89% of studies demonstrated a reduction in 30-day readmissions following implementation of a pharmacy-led transitions-of-care program. The 2 most impactful services included medication reconciliation and provision of medication education at discharge, with patients having a CMS HRRP diagnosis or high-risk characteristic (ie, polypharmacy, poor health literacy, > aged 65 years, high-risk medications, recent readmissions, chronic disease states) benefiting the most.6

Optimizing Pharmacy Contributions to Medication Reconciliation

WHO recommends that pharmacy team members obtain the best possible medication history (BPMH) by thoroughly documenting all medications as reported by the patient or caregiver and confirmed using a second source providing external prescription history (eg, Surescripts).7 Ideally, a proactive model is followed, which completes the BPMH upon admission as a distinct step prior to the prescriber entering inpatient orders.7

Allocating pharmacy resources to the task of admission and discharge reconciliation is also the best method for preventing medication-related problems, particularly for medically complex patients.8 Inclusion of pharmacy technicians, students, or residents in the reconciliation process show no difference in efficacy.8,11 Utilization of pharmacy extenders (ie, pharmacy technicians, students, residents) and utilization of medication-related criteria (eg, polypharmacy, high-risk medications, recent medication changes) to identify patients benefiting most from pharmacy-provided services may be considerations for health care organizations when resources are limited.5,7,8 For additional value, pharmacy should also provide patient education, construct medication calendars, and coordinate postdischarge follow-up.

Future efforts should be directed toward designing best practice models and developing service line funding strategies. This way, hospitals can take advantage of the important contributions that pharmacy can make to the medication reconciliation process.


  1. Institute for Healthcare Improvement. Medication reconciliation to prevent adverse drug events. Accessed March 31, 2023.
  2. Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: A consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5(8):477-485. doi:10.1002/jhm.849
  3. Joint Commission. National Patient Safety Goals 2023. Accessed March 31, 2023.
  4. Marshall J, Hayes BD, Koehl J, et al. Effects of a pharmacy-driven medication history program on patient outcomes. Am J Health Syst Pharm. 2022;79(19):1652-1662. doi:10.1093/ajhp/zxac143
  5. Rodrigues CR, Harrington AR, Murdock N, et al. Effect of pharmacy-supported transition-of-care interventions on 30-day readmissions: a systematic review and meta-analysis. Ann Pharmacother. 2017;51(10):866-889. doi:10.1177/1060028017712725
  6. Harris M, Moore V, Barnes M, Persha H, Reed J, Zillich A. Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review. J Am Pharm Assoc (2003). 2022;62(5):1477-1498.e8. doi:10.1016/j.japh.2022.05.017
  7. Action on Patient Safety (High 5s) Initiative, World Health Organization. The High5s Project: standard operating protocol. Assuring medication accuracy at transition in care: medication reconciliation. Version 3. Published September 2014. Accessed March 31, 2023.
  8. Choi YJ, Kim H. Effect of pharmacy‐led medication reconciliation in emergency departments: A systematic review and meta‐analysis. J Clin Pharm Ther. 2019;44(6):932-945. doi:10.1111/jcpt.13019
  9. Hovey SW, Click KW, Jacobson JL. Effect of a pharmacist admission medication reconciliation service at a children’s hospital. J Pediatr Pharmacol Ther. 2023;28(1):36-40. doi:10.5863/1551-6776-28.1.36
  10. Fernandes BD, Almeida PHRF, Foppa AA, Sousa CT, Ayres LR, Chemello C. Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy. 2020;16(5):605-613. doi:10.1016/j.sapharm.2019.08.001
  11. Punj E, Collins A, Agravedi N, Marriott J, Sapey E. What is the evidence that a pharmacy team working in an acute or emergency medicine department improves outcomes for patients: A systematic review. Pharmacology Res & Perspec. 2022;10(5):e01007. doi:10.1002/prp2.1007

About the Authors

Marla C. Tanski, PharmD, MPH, MS, BCPPS, is a clinical pharmacy manager at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida.

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