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Overview and Description

Background:  The Institute of Medicine’s reported To Err is Human: Building a Safer Health System came out in 2000. The institute estimated 98,000 Americans were dying annually due to medical errors (Kohn, Corrigan, & Donaldson, 2000).  Then in 2002, Institute of Medicine (IOM) report called Crossing the Quality Chasm described the US system as decentralized, complicated and poorly organized.  It specifically noted “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.”  Qualitative evidence increasingly indicates that patient safety is jeopardized during transition of care (Institute of Medicine, 2002).  Then in 2006, IOM’s Preventing Medication Errors reported the average hospitalized patient is subject to at least one medication error per day, making medication errors represent the most common patient safety error (Institute of Medicine, 2007).  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 result in harm. Many of these errors would be averted if medication reconciliation processes were in place (Institute of Medicine, 2007)

During that time, 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 effective January 1, 2003.  Changes in this area can improve quality of care and can both reduce costs and 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 (National Patient Safety Goals 2020, 2020).

One of the National Patient Safety Goals in 2005 is medication reconciliation across the care continuum.  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.  It is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking.  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. This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient. (National Patient Safety Goals 2020, 2020)

Then in 2009, MATCH study was done to determine risk factors and potential harm associated with medication errors at hospital admission (Gleason, McDaniel, & et al, 2010).  The results showed over one-third of study patients (35.9%) experienced order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful.  Patient’s age≥65 and number of prescription medications were significantly associated with errors potentially requiring monitoring or causing harm. Presenting a medication list or bottles at admission was beneficial.   It is recommended that attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists.  MATCH toolkit for medication reconciliation was published for use (Gleason, Brake, Agramonte, & Perfetti, 2021).

What has changed in the last twenty years?  It has been estimated that annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which makes medical errors the country’s third-leading cause of death  (National Patient Safety Goals 2020, 2020) Medication discrepancies (errors) arising at care transitions have been reported as prevalent and are linked with adverse drug events.  ECRI (originally founded as Emergency Care Research Institute) continued to name continuum of care as top 10 patient safety concerns for 2020 because of the importance of collaboration in patient safety (ECRI, 2020). Fragmentation across setting care settings 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.”  Transition of care is defined as a continuous process in which a patient’s care shifts from one hospital setting to another, such as from an acute hospital facility to an acute inpatient rehabilitation facility to skilled nursing facility.  Poorly managed transitions of care not only increase health care costs and decrease quality of care but most importantly, adversely affect patient safety (ECRI, 2020).

Medication safety continues to be one of the Joint Commission National Patient Safety Goals through the years, including 2021 (National Patient Safety Goals 2020, 2020).  Medication safety goals includes (1) labelling all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings, (2) reduce the likelihood of patient harm associated with the use of anticoagulant therapy and (3) maintain and communicate accurate patient medication information.  It is suggested that the health care systems focus on how to record and pass along correct information about a patient’s medicines by finding out what medicines the patient is taking and comparing those medicines to new medicines given to the patient.  It is suggested to give the patient written information about the medicines they need to take and to instruct the patient that it is important to bring their up-to-date list of medicines every time they visit a doctor.  Five reasons for medication reconciliation: 1) Reconciliation has the substantial potential to improve patient outcomes. 2) A correct medication list will prevent problems from occurring, which may take more time to resolve. 3) Strategies are already available to facilitate developing and maintaining the correct medication list. 4)  A correct medication list offers the opportunity to deprescribe. 5) A correct medication list is what patients want and need (National Patient Safety Goals 2020, 2020)

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 patient safety and maintaining quality of care in addition to minimizing in healthcare costs.  One aspect of transition of care that can dramatically reduce the number of sentinel events for a rehabilitation facility is medication reconciliation.  Failure to reconcile medications across transition of care is a key source of sentinel events that can ultimately lead to discharge back to the acute care facility.   The steps in medication reconciliation are seemingly straightforward (Parson & Brandt, 2019).   Acute inpatient rehabilitation medication reconciliation will be different when compare to a newly hospitalized patient wherein for a newly hospitalized patient, the steps include 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 steps include determining the post-discharge medication regimen, developing discharge instructions for the patient for home medications, educating the patient, and transmitting the medication list to the follow-up physician. For patients in ambulatory settings, the main steps include documenting a complete list of the current medications and then updating the list whenever medications are added or changed (Kreckman, Wasey, & Wise, 2018)

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. Oftentimes these are sufficient for transition of care but there are instances when additional records would be crucial for continuity of quality care. However, the process of gathering, organizing, and communicating medication information across the continuum of care is complex.  The process for gathering a patient’s medication history is wide-range and multidisciplinary —medicine, pharmacy, and nursing with non-concurrent role and responsibility for the reconciliation process. (Kreckman, Wasey, & Wise, 2018).  There is often data gathering repetition with both nurses and physicians taking medication histories, documenting them in different places in the chart, and rarely comparing and resolving any discrepancies between the two histories (Kalu, Maximosa, Sengiada, & Dal Belllo-Haasb, 2019).

A study on potential medication discrepancies during medication reconciliation in Post-Acute-Long term care setting evaluated the discrepancies between the initial physician order sheet physician order set(POS), hospital discharge summary, electronic health record (EHR), health information exchange (HIE), and the patient interview/home medication list (Kalu, Maximosa, Sengiada, & Dal Belllo-Haasb, 2019).  Of all orders, 30% contained a discrepancy. The average number of discrepancies per medication source per patient included: 5.6 for the hospital discharge summary, 7.6 for the EHR, and 9.6 for the home medication list/interview. 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 (Hill, Varma, Price, & Kasner, 2015).

Stroke is one of the most common diagnosis of patients that is 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 finally home. While expertise at different stages of treatment and recovery has been shown to reduce patient morbidity and mortality, transitions across these care environments can be hazardous.  For such medically complicated patients, errors at the time of transfer across care environments are common and may be associated with adverse events and readmission.  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.  (Hill, Varma, Price, & Kasner, 2015).

Cutting Edge/ Unique Concepts/ Emerging Issues

Concept of toolkits was developed to guide institutions on medication reconciliation.  One toolkit mentioned was the MATCH Toolkit for Medication Reconciliation (Gleason, Brake, Agramonte, & Perfetti, 2021).  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 United States implemented interventions from a best practices toolkit to improve medication reconciliation (Schnipper, Mixon, & Stein, 2018)). In 2018 a Cochrane database of systematic review on the impact of medication reconciliation for improving transitions of care to assess the effect of medication reconciliation on medication discrepancies, patient-related outcomes and healthcare utilization in people receiving medication reconciliation intervention during transitions of care was compared to those not receiving medication reconciliation (Redmond, Grimes, & et al, 2018). The systematic review included 25 randomized trials from 8 countries with 23 studies that were provider oriented (pharmacist mediated) and 2 structural (electronic reconciliation tool and medical record changes).  Studies mainly included older people prescribed multiple medications. While many studies reduced the presence of at least one medication discrepancy in people receiving the intervention, the study team was uncertain 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 (Redmond, Grimes, & et al, 2018). This leads to emerging issue on how to reliably reduced medication reconciliation errors when strategies applied have been varied. 

Gaps in Knowledge/ Evidence Based

There is a gap in data knowledge to guide hospitals as to which interventions are the most effective at improving 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 (Mixon, Kripalani, & et al, 2019). 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) (Grossman, Gourevitch, & et al, 2014). This study recommended that hospitals should focus first on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating roles and responsibilities of clinical staff. Hospitals are cautioned when implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study. (Grossman, Gourevitch, & et al, 2014).


ECRI = originally founded as Emergency Care Research Institute is an independent nonprofit organization improving the safety, quality, and cost-effectiveness of care across all healthcare settings worldwide.

IOM = Institute of Medicine is a nonprofit organization specifically created for science-based advice on matters of biomedical science, medicine, and health as well as an honorific membership organization. It was chartered in 1970 as a component of the National Academy of Sciences. The Institute provides a vital service by working outside the framework of government to ensure scientifically informed analysis and independent guidance. The IOM’s mission is to serve as adviser to the nation to improve health. The Institute provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy to policy-makers, professionals, leaders in every sector of society, and the public at large.

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.

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.

Transition of care= is defined as a continuous process in which a patient’s care shifts from one hospital setting to another, such as from an acute hospital facility to an acute inpatient rehabilitation facility to skilled nursing facility.


ECRI. (2020, December 15). Retrieved from Medication Safety: reduce the Occurece of medication Errors with evidence-informed best practices: https://www.ecri.org/solutions/medication-safety/

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.

Gleason, K., Brake, H., Agramonte, V., & Perfetti, D. (2021, August). Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation,. Retrieved from AHRQ: http://www.ahrq.gov/qual/match/

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.

Hill, C. E., Varma, P., Price, R. S., & Kasner, S. E. (2015). Reduding errors in transition from acute stroke hospitalization to inpatient rehabilitation. Front Neurol 6, 227.

Institute of Medicine. (2002). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.

Institute of Medicine. (2007). Preventing Medication Errors. Washington, DC: National Academies Press.

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.

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press.

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.

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.

National Patient Safety Goals 2020. (2020, December 15). Retrieved from The Joint Commission: https://www.jointcommission.org/standards/national-patient-safety-goals/

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.

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.

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.

Original Version of the Topic

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

Author Disclosure

Marilyn Pacheco, MD
Nothing to Disclose

Jeffrey Oken, MD
Nothing to Disclose