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- Incomplete or outdated records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 |