Author(s): Charnette Lercara, MD, Lon Yin Chan, MD, Elver Ho, MD, Ahmed Elzayat, BA
Originally published: April 18, 2016 Last updated: June 27, 2024
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Overview and Description

Background:  The Institute of Medicine (IOM) published a report To Err is Human: Building a Safer Health System in 2000 that estimated that 98,000 annual deaths in America could be attributed to medical errors.9 The follow-up report Crossing the Quality Chasm described the US system as decentralized, complicated and poorly organized and patient safety is jeopardized during transition of care.17 IOM’s Preventing Medication Errors reported that the average hospitalized patient is subject to at least one medication error per day, making medication errors the most common patient safety error.17 More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients. Of these errors, about 20 percent are believed to have resulted in harm. Many of these errors would be averted if medication reconciliation processes were in place.17

As these findings came to light, the Joint Commission established National Patient Safety Goals (NPSGs) in 2002 to help accredited organizations address specific areas of concern in patient safety and the first set of NPSGs was in effect beginning January 1, 2003. These goals have been reviewed and revised annually and help to improve quality of care, reduce costs, and limit the number of sentinel events. Sentinel events are any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient’s illness.12,13

Several NPSGs help reduce the likelihood of sentinel events, especially in regards to medication reconciliation, communication among caregivers, and hand-off to improve patient care

Patient identification

The most basic step to establishing good care, especially in transition of care, is to ensure proper patient identification at every step from admission (e.g., wristband) to medication to procedures. It is important to use at least two patient identifiers when providing care, treatment, and services to correctly identify the individual and to match the service to that individual. Other strategies include asking patients to confirm the two patient identifiers such as name and date of birth, avoid using physical location or room number, labeling containers in the presence of the patient, and establishing communication tools among staff (e.g., alerts for similar names).

Universal protocol

The Universal Protocol applies to all surgeries and noninvasive procedures to help prevent three things: wrong patient, wrong site, and wrong procedure.

  • Preparing for the procedure beforehand: Verify that necessary equipment is available and that patient identifiers are used appropriately wherever appropriate. It’s best to also review the procedure and reasoning for it with the medical team and the patient.  Procedure verification and review can be done multiple times and at any point prior (e.g., when procedure is scheduled, entering the procedural room)
  • Marking the site of procedure: Especially in cases where there will be more than one insertion site, marking the site is advisable. The mark should be consistent and unambiguous and performed by an eligible individual who is familiar with the patient and will be present during the procedure.
  • Conducting a time-out: Shortly before carrying out the procedure, the medical team should pause for a “time-out” to verify and document, at the very least, the patient identity, the correct site, and the procedure. A time-out should be conducted before each procedure, even if by the same team in the same room.

In short, the key to preventing sentinel events by the Universal Protocol is to establish a consistent method of identifying patients and preparing for procedures, and always with patient involvement whenever possible.

Medication reconciliation

One key component of patient care to help prevent sentinel events is medication reconciliation. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders.  This process compares a patient’s medications orders to all of the medications that the patient has been taking prior to admission.  This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.  It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care.

In 2024, the NPSG also included five items for performance for healthcare organizations: (1) obtain the current list of the patient’s current medications when admitted or in an outpatient setting; (2) define the types of medication information to be collected in non-24 hour clinical settings such as the emergency department; (3) compare the medication information the patient brings with the ones ordered/to be ordered by the healthcare providers; (4) provide the patient (or family, caregiver, proxy) with written information on the medications the patient should be taking when discharged; (5) explain the importance of managing medication information to the patient when they are discharged.12,13

In 2009, the Medications At Transitions and Clinical Handoffs (MATCH) study was designed to determine risk factors and potential harm associated with medication errors at hospital admission.2 The prospective study found that over a third of patients had inaccurate medication reconciliation, most of which were either inaccurately obtained from medication history or omitted. It also demonstrated that there was a significantly increased rate of harm or intervention, or potential harm as a result of inaccurate medication reconciliation. A couple of take-home points presented themselves:

  • Asking patients for a medication list or bottles at admission was beneficial.
  • Older patients, especially above the age of 65, should have a more focused medication history given the likelihood of polypharmacy.
  • Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists. 

The study informed the creation of MATCH toolkit for medication reconciliation which is still being used today to help hospitals create their own medication reconciliation system. The MATCH Toolkit for Medication Reconciliation was created from the findings of the MATCH study in 2010.2 This toolkit provides clinicians with a step-by-step guidance on creating a medication reconciliation system that fits one’s institution, from planning and gaining buy-in to implementing the process to educating employees to use the system.3 

Another toolkit is the MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) toolkit.  MARQUIS was a pragmatic, mentored, quality improvement (QI) study in which 5 hospitals in the United States implemented interventions from a best practices toolkit to improve medication reconciliation.16

Hand-off communication

Effective communication during hand-off and transition of care is essential. A technique commonly used for standardized communication between physicians and other clinicians is the SBAR method. The SBAR stands for Situation, Background, Assessment, and Recommendations (or Request).18

  • Situation is a brief statement about what is currently happening about the patient with identifiers. “What is going on with the patient?”
  • Background provides context with pertinent information such as patient background, labs results. “What is the clinical background or context?”
  • Assessment reports what the person communicating the SBAR thinks the problem is based on their review or clinical assessment of the patient. “What do I think the problem is?”
  • Recommendations and Requests states an initial recommendation on what and when to do, or what to follow up. Repeating the information by the listener is also important to ensure accurate information is being relayed.

This standardized method allows for concise communication between team members, allows for individuals to bring attention to matters, and reorients the listener to pertinent information to ensure patient care remains uncompromised. This format can be adapted to communicate information to patients and caregivers as well.18

What has changed in the last twenty years?

The estimated annual patient deaths due to medical errors have since risen steadily to 440,000 lives, making medical errors the country’s third-leading cause of death.12,13 Medication discrepancies (or errors) arising at care transitions have been reported as prevalent and are linked with adverse drug events.  The Emergency Care Research Institute (ECRI) continued to name continuum of care as one of the top 10 patient safety concerns for 2020.1 Discrepancies across  care settings during transitions continues to be part of the concerns because “breakdowns in care from a fragmented healthcare system can lead to readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures and general patient and provider dissatisfaction.”1  This continuum of care process, in which a patient’s care shifts from one hospital setting to another–from an acute hospital facility to an acute inpatient rehabilitation facility to a skilled nursing facility, for instance– is what we commonly term transition of care.  Poorly managed transitions of care not only increase health care costs and decrease quality of care but most importantly, adversely affect patient safety.1

Medication safety continues to be one of the Joint Commission National Patient Safety Goals through the years.12,13 Medication safety goals includes (1) labeling all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings, (2) reducing the likelihood of patient harm associated with the use of anticoagulant therapy and (3) maintaining and communicating accurate patient medication information. Health care systems should focus on how to record and pass along correct information about a patient’s medicines by comparing what the patient has been taking to new medicines given to the patient. They should also provide the patient with written information about the medications they need to take and remind the patient to bring their up-to-date list of medicines every time they visit a doctor. 

In summary, there are five main reasons why medication reconciliation is so critical12,13

  • Reconciliation has the substantial potential to improve patient outcomes.
  • A correct medication list will prevent problems from occurring, which may take more time to resolve.
  • Strategies are already available to facilitate developing and maintaining the correct medication list.
  • A correct medication list offers the opportunity to deprescribe.
  • A correct medication list is what patients want and need.

Relevance to Clinical Practice

As the acuity of patients being admitted to inpatient rehabilitation facilities (IRF) increases, a detailed transition of care report amongst providers should be expected for maintaining patient safety and quality of care in addition to minimizing healthcare costs. Medication reconciliation performed whenever transferring patients in straightforward.14 For a new patient in the hospital, medication reconciliation is done by obtaining and verifying the patient’s medication history, documenting the patient’s medication history, writing orders for the hospital medication regimen, and creating a medication administration record.  At discharge, the provider determines the post-discharge medication regimen, develops discharge instructions for the patient for home medications, educates the patient, and transmits the medication list to the follow-up physician. For patients in ambulatory settings, reconciliation primarily includes documenting a complete list of the current medications and then updating the list whenever medications are added or changed.10

Traditionally, the transition of care between an acute care facility and IRF consists of a discharge summary, discharge medication reconciliation, medication administration report, and physician documentation. However, the process of gathering, organizing, and communicating medication information across the continuum of care is complex and multidisciplinary —medicine, pharmacy, and nursing with a non-concurrent role and responsibility for the reconciliation process.10 Data gathered by multiple different team members (e.g., nurse and doctor) are often documented in different places of the chart, and rarely are any discrepancies between two histories resolved.8

A study on potential medication discrepancies during medication reconciliation in Post-Acute-Long term care setting showed that the most frequent types of discrepancies included: omission of medication orders between lists (42.7%), additional medications not included on the initial POS (24.6%), and discrepancies in frequency (11.8%). The hospital discharge summary proved to be the medication source that provided the least number of discrepancies, compared to the initial POS.5

In addition, the concepts of proper patient identification and Universal Protocol for procedures apply to rehab of all levels. As PM&R can be procedure heavy, it is important to use the Universal Protocol to prevent wrong patient, wrong site, and wrong medication.

Stroke is one of the most common diagnoses of patients that are admitted to acute inpatient rehabilitation.  Stroke care spans a continuum of care environments, from the emergency room to the stroke unit to the rehabilitation facility and to discharge. While expertise at different stages of treatment and recovery has been shown to reduce patient morbidity and mortality, having multiple points of transition of care create opportunities for error and adverse events, especially for medically complex patients, leading to potential readmissions. A study on reducing errors in transition from acute stroke hospitalization to inpatient rehabilitation showed standardized handoffs decreased errors in communication of diagnosis and critical medications for secondary stroke prevention.5

Cutting Edge/Unique Concepts/Emerging Issues

Medication reconciliation has largely transitioned over to an electronic delivery rather than paper-based process. Multiple methods of medication reconciliation have been studied to improve the process including standardized forms, interdisciplinary (e.g., nurse-pharmacy) collaboration, and pharmacy-led programs.1

Medical reconciliation and hand-off communication will evolve with the implementation of artificial intelligence and machine learning in healthcare. Long et al. have developed a promising AI-driven tool to perform medication reconciliation accurately with patient involvement, thus informing them of their medications and reducing the burden on clinicians.21 Other tools in the works include AI-tool for perioperative hand-off which can go beyond standardized checklist and make informed suggestions after synthesizing clinical data (e.g., what are the priority issues to focus for the next team?).20 Using AI may also help with cleaning up any discrepancies from multiple visits or history-taking from multiple personnel. AI research is still up and coming but may play a pivotal role in the near future.

In 2018, a Cochrane systematic review of the impact of medication reconciliation for improving transitions of care was published. While it found that most reported fewer medication discrepancies that required intervention, the review remained ambivalent on whether reconciliation reduced discrepancies as the reliability of the evidence was very low. The evidence for the intervention’s effect on the number of discrepancies and on clinical outcomes such as actual and preventable medication side effects, combined measures of healthcare utilization and unplanned readmissions to hospital itself was varying with evidence ranging from moderate to low or very low reliability.15 This leads to a new question: how do we know which strategy is the best practice to reliably reduce medication reconciliation mistakes when there are so many?

Gaps in Knowledge/Evidence Based

There remains a question as to which interventions are the most effective at improving the medication reconciliation process and reducing harm. An on-treatment analysis of MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) found three interventions were associated with significant decreases in potentially harmful discrepancy rates: (1) defining clinical roles and responsibilities, (2) training, and (3) hiring staff to perform discharge medication reconciliation.11 Two interventions were associated with significant increases in potentially harmful discrepancy rates: training staff to take medication histories and implementing a new electronic health record (EHR).4 Hospitals should focus  on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating the roles and responsibilities of clinical staff. Secondly, they should take caution when implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study.4

Artificial intelligence is also in its nascent stage, and more research will be required before wide implementation.

References

  1. ECRI. Retrieved from Medication Safety: reduce the Occurrence of medication Errors with evidence-informed best practices: https://www.ecri.org/solutions/medication-safety/
  2. Gleason, K. M., McDaniel, M. R., & et al. (2010). Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission . J Gen Intern Med 25 (5), 441-7.
  3. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. Content last reviewed April 2023. Agency for Healthcare Research and Quality, Rockville, MD.        https://www.ahrq.gov/patient-safety/settings/hospital/match/index.html     
  4. Grossman, J., Gourevitch, R., & et al. (2014). Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation July 2014. . National Institute for Health Care Reform Research Brief, N. 17.
  5. Hill, C. E., Varma, P., Price, R. S., & Kasner, S. E. (2015). Reducing errors in transition from acute stroke hospitalization to inpatient rehabilitation. Front Neurol 6, 227.
  6. Institute of Medicine. (2002). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.
  7. Institute of Medicine. (2007). Preventing Medication Errors. Washington, DC: National Academies Press.
  8. Kalu, M. E., Maximosa, M., Sengiada, S., & Dal Belllo-Haasb, V. (2019). The Role of Rehabilitation Professionals in Care Transitions for Older Adults: A Scoping Review. Physical and Occupational Therapy in Geriatrics 37 (3), 123-150.
  9. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press.
  10. Kreckman, J., Wasey, W., & Wise, S. (2018). Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team. BMJ Open Quality, 7.
  11. Mixon, A., Kripalani, S., & et al. (2019). An On-Treatment Analysis of MARQUIS Study: Interventions to Improve Inpatient Medication Reconciliation. Journal of Hospital Medicine, Vol 14, No 10.
  12. National Patient Safety Goals 2024. Retrieved from The Joint Commission: https://www.jointcommission.org/standards/national-patient-safety-goals/
  13. National Patient Safety Goals 2024. (2024, October 4). Retrieved from The Joint Commission:https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
  14. Parson, J., & Brandt, N. (2019). Identifying Potential Medication Discrepancies During Medication Reconciliation in the Post-Acute Long-Term Care Setting. Journal of Gerontological Nursing 45(7), 5-10.
  15. Redmond, P., Grimes, T. C., & et al. (2018). T. Impact of medication reconciliation for improving transitions of care. Cochrane Database of Systematic Reviews, Issue 8.
  16. Schnipper, J. L., Mixon, A., & Stein, J. (2018). Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ Qual Saf 27, 954-964.
  17. Cohen MR. The Institute of Medicine report, preventing medication errors: another good day. Am J Health Syst Pharm. 2007;64(14 Suppl 9):S1-S2. doi:10.2146/ajhp070189
  18. Tool: SBAR. Content last reviewed November 2019. Agency for Healthcare Research and Quality, Rockville, MD.        https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/sbar.html     
  19. Babel, A., Taneja, R., Mondello Malvestiti, F., Monaco, A., & Donde, S. (2021). Artificial Intelligence Solutions to Increase Medication Adherence in Patients With Non-communicable Diseases. Frontiers in digital health, 3, 669869. https://doi.org/10.3389/fdgth.2021.669869
  20. Sparling JL, Hong Mershon B, Abraham J. Perioperative Handoff Enhancement Opportunities Through Technology and Artificial Intelligence: A Narrative Review. Jt Comm J Qual Patient Saf. 2023;49(8):410-421. doi:10.1016/j.jcjq.2023.03.009
  21. Long J, Yuan MJ, Poonawala R. An Observational Study to Evaluate the Usability and Intent to Adopt an Artificial Intelligence-Powered Medication Reconciliation Tool. Interact J Med Res. 2016;5(2):e14. Published 2016 May 16. doi:10.2196/ijmr.5462

Original Version of the Topic

Jeffrey Oken, MD, Raj Desai, MD. Transition of Care and Medication Reconciliation. 4/18/2016

Previous Revision (s) of the Topic

Marilyn Pacheco, MD, Jeffrey Oken, MD. Medical Reconciliation/Hand-offs Care. 5/11/2021

Author Disclosure

Charnette Lercara, MD
Nothing to Disclose

Lon Yin Chan, MD
Nothing to Disclose

Elver Ho, MD
Nothing to Disclose

Ahmed Elzayat, BA
Nothing to Disclose