Medication reconciliation is a process designed to improve communication and promote teamwork. This has the objectives of preventing medication errors associated with the handover of care19and maintaining continuity of care. It is described as the formal process of obtaining, verifying and documenting an accurate list of a patient's current medicines on admission and comparing this list to the admission, transfer and discharge orders, to identify and resolve discrepancies. 13,20,21 At the end of each episode of care the verified information is transferred to the next care provider and provided to the patient or carer.21 This information includes changes made to the medicines during the episode of care. There are a number of discrete steps (Fig. 1). The process is based on the safety principle of independent redundancies – having independent checks, generally by different providers, for key steps in the process.13The process aligns with the principles recommended to achieve continuity of medication management in Australia.22
The best possible medication history
A 'best possible medication history' is the cornerstone of the medication reconciliation process. It is described as a comprehensive drug history obtained by a clinician that includes a thorough history of all regular medicines used, including non-prescription and complementary medicines, and is verified by more than one source. A structured process for taking the history, that involves the patient or carer or family, using a checklist to guide the interview, and that verifies the history with information from a number of different sources, provides the best assessment of the drugs a patient takes at home.4
Sources used to obtain a comprehensive history are listed in Fig. 1 (step 2). Patients being admitted to hospital should be advised to take their medicines containers and current medicines list.
Ideally the best possible medication history is completed before any drugs are ordered and is used when the medication chart is written up. For unplanned admissions the history is usually completed after the initial medication orders have been written and is used to reconcile the orders.
In the community the general practitioner can refer to the community pharmacy for a list of dispensed medicines or request a Home Medicines Review to determine the medicines currently taken. This best possible medication history should be reconciled with the current medication list in the patient's record and their condition.
Standardised reconciling form
A standardised form for recording the best possible medication history and reconciling any discrepancies is essential for effective medication reconciliation. Whether electronic or paper based, the form should be kept in a consistent, highly visible position in the patient's notes and be easily accessible by all clinicians when writing medication orders and reviewing the patient.19
In Australia the National Medication Management Plan* can be used to record the history and reconcile medication orders in patients admitted to hospital.
Electronic solutions
Computerised systems (e-prescribing) may prevent many of the medication errors that occur at transfers of care but these systems are not without their problems. They still require someone to enter an accurate list of drugs and allergies..Medication lists in electronic records can lag behind prescription changes and be incomplete.12For example, they may only contain the medicines prescribed in a particular system, and not include non-prescription products or medicines prescribed by other practitioners. Outdated, unverified or inaccurate information may be transferred indefinitely when using copy-and-paste facilities, so reconciliation is still required.13