Medicines Reconciliation
Medicines reconciliation is the process of creating an accurate list of a patient's medications at every care transition, identifying and resolving discrepancies to prevent errors.
Key Facts
Medicines reconciliation should occur within 24 hours of admission to hospital (NICE NG5) Up to 70% of patients have at least one discrepancy between their admission medications and GP records The most common discrepancies are omitted medicines, incorrect doses, and unintentional additions Medicines reconciliation reduces medication errors at care transitions by up to 70% A minimum of two sources should be used to verify medication history (e.g., patient, GP summary, community pharmacy) High-risk medications (anticoagulants, insulin, opioids, immunosuppressants) require particular attention during reconciliation The process should be pharmacist-led where possible (NICE NG5) Discharge medicines reconciliation is equally important — unintentional changes must be communicated to GP
Overview
Key Facts
Medicines reconciliation is a critical patient safety process that prevents medication errors at transitions of care. NICE defines it as 'the process of identifying an accurate list of a person's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes.'
Epidemiology
Studies show:
- 30-70% of patients have at least one medication discrepancy on admission
- 12-17% of these discrepancies have the potential to cause harm
- 50% of medication errors at hospital discharge involve discrepancies not communicated to primary care
- NICE estimates that effective reconciliation could prevent ~30,000 ADR-related admissions per year in England
Aetiology
Discrepancies arise due to:
- Multiple prescribers (GP, hospital, specialist clinics)
- Poor communication between care settings
- Patient self-medication (OTC drugs, supplements)
- Medication changes during admission not documented
- Incomplete or outdated records
Pathophysiology
N/A — this is a process/systems topic rather than a disease entity.
Clinical Presentation
Types of Discrepancy
- Omission: Regular medication not prescribed on admission
- Commission: Drug prescribed that patient was not taking
- Wrong dose/frequency: Incorrect transcription of dose
- Duplication: Same drug or therapeutic class prescribed twice
- Drug interaction: New combination creating interaction
High-Risk Scenarios
- Emergency admissions (limited medication history available)
- Elderly patients with polypharmacy
- Patients with cognitive impairment
- Patients transferring between hospitals
- Discharge to care homes
Red Flags
- Omission of critical medications (anticoagulants, anti-epileptics, immunosuppressants, insulin, steroids)
- Abrupt cessation of medications requiring tapering (beta-blockers, steroids, opioids, benzodiazepines)
- Duplication of therapy (e.g., two ACE inhibitors)
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Intentional change | Documented clinical decision to alter medication | Review clinical notes, speak to prescriber |
| Unintentional discrepancy | No documented reason for medication change | Clarify with patient and prescriber |
| Non-adherence | Patient not taking medicines as prescribed pre-admission | Patient interview, GP records |
| Self-medication | Patient taking OTC/herbal/recreational drugs | Direct questioning |
| Prescribing cascade | New drug treating side effect of another drug | Comprehensive medication review |
| Inappropriate continuation | Hospital-initiated drug continued beyond indication | Review indication and duration |
Diagnosis / Investigation
Bedside
- Structured medication history: Using open and closed questioning
- Patient's own drugs (PODs): Inspect brought-in medications
- Compliance aids: Check dosette boxes, blister packs
Information Sources (Minimum Two Required)
- Patient/carer interview: Primary source
- GP Summary Care Record: Electronic access to GP prescriptions
- Community pharmacy records: Dispensing history
- Repeat prescription printout: From GP surgery
- Care home MAR charts: Medication administration records
- Previous discharge summaries: From hospital records
- Specialist clinic letters: For hospital-initiated medications
Special Tests
- Drug levels: If adherence questioned or toxicity suspected
- Medication review: Using STOPP/START criteria for older adults
Management
Non-pharmacological
- Standardised process: Follow NICE NG5 guidance
- Pharmacist-led reconciliation: Within 24 hours of admission
- Patient involvement: Encourage patients to carry an up-to-date medication list
- Documentation: Record reconciliation outcome in clinical notes
- Communication: Ensure all changes communicated at discharge (discharge summary within 24 hours)
Pharmacological
- No specific pharmacological management — this is a process-driven intervention
- All discrepancies should be resolved with the responsible clinician
- Unintentional omissions should be re-prescribed
- Unintentional additions should be deprescribed
Process Steps
- Collect: Gather medication information from ≥2 sources
- Compare: Match against current inpatient prescription
- Resolve: Identify and resolve discrepancies with prescriber
- Document: Record the verified list and any changes made
- Communicate: Share updated list with patient and all providers
Referral Criteria
- Complex polypharmacy → specialist pharmacist review
- Recurrent medication errors → patient safety team
- Safeguarding concerns (medication misuse) → appropriate safeguarding referral
Prognosis
- Effective medicines reconciliation reduces medication errors at transitions by up to 70%
- Pharmacist-led reconciliation at admission reduces potential ADR-related harm by approximately 50%
- Structured discharge reconciliation reduces 30-day readmission rates by approximately 20%
- The cost-effectiveness of pharmacist-led reconciliation is well-established — estimated to save the NHS £3-£5 for every £1 invested
- Despite evidence, full implementation remains variable across NHS trusts
Other Relevant Information
STOPP/START Criteria (Relevant to Medication Review)
| Criteria | Purpose | Examples |
|---|---|---|
| STOPP | Potentially inappropriate medications in older adults | PPIs without indication >8 weeks, long-term benzodiazepines |
| START | Medications that should be considered | Statins in diabetes with CV risk, vitamin D in frail elderly |
Key NICE Recommendations (NG5)
| Recommendation | Detail |
|---|---|
| Timing | Within 24 hours of admission |
| Responsibility | Pharmacist-led where possible |
| Sources | Minimum of 2 independent sources |
| Discharge | Changes communicated to GP within 24 hours |
| Patient involvement | Provide written list of medications on discharge |