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Mandumpala                                                                                                                                       Medication reconciliation  

Vol 2 | Issue 1 | Jan – Mar 2023                                                                                             Indian J Pharm Drug Studies | 1  

Review Article 

Medication Reconciliation – A patient safety strategy  

Janice Jacson Mandumpala  

From, Pharm D intern, Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha,Kerala, India. 

Correspondence to: Janice Jacson Mandumpala, Pharm D Intern, Department of Pharmacy Practice, Nirmala College of Pharmacy, 

Muvattupuzha, Kerala, India – 686661. Email: janice.jacson@gmail.com  

ABSTRACT  

Patient safety is an international concern and mandates the attention of healthcare professionals. Recently, it has been recognized that 

multiple strategies and members of the healthcare team from the treating physician to the dispensing pharmacist have a key role to play in 

assuring patient safety. One such role is that of the clinical pharmacist and the medication reconciliation conducted by them. It is done to 

get a thorough understanding of the patient medical history, medication history, drug allergy history and many others that could be a loophole 

for patient harm. This review summarizes a brief review about what is patient safety, and the patterns of employing medication reconciliation 

in different clinical scenarios that is the emergency department, in transitions of care and in geriatric care. It is specifically important to 

address the role of growing technology in the same field and so we have also enlisted the ongoing efforts done in the same domain. This 

review also addresses the role of clinical pharmacists and their emerging responsibility in maintaining a patient safety culture.  

Key words: Medication reconciliation, Patient safety, Emergency department, Geriatric care, Clinical pharmacists

edication reconciliation has the potential to reduce 

significant morbidity and mortality. This in turn causes 

financial strain on the healthcare system and is a source 

of preventable costs. It is an important piece of the medication 

puzzle. Medication reconciliation is an inevitable aspect while 

ensuring patient safety and quality. It is a major intervention that 

tackles the issue of medication discrepancies and avoids patient 

harm, particularly during care transitions. Medication 

reconciliation clarifies, corrects and specifies the medications 

the patients are consuming at different durations of their 

hospitalization, followed by the necessary corrections on the 

medical records. A medication reconciliation program also 

reduces confusion regarding the medications that the patient is 

using and has a major contribution in preventing unintentional 

medication changes, all of which cause a major resource strain on 

the hospital. This paves the way to maintain a standardized pattern 

of patient care in a care facility [1,2].  

According to the Joint Commission, the steps involved in 

medication reconciliation are as follows [3]: ‘(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.’  

PATIENT SAFETY CULTURE  

Nurturing a culture of safety is the core aspect of promoting 

quality care among patients. Safety culture within healthcare 

institutions has proven to reduce errors, and mortality and reduce 

adverse drug events [4–6]. It influences clinicians, clinical 

pharmacists, nurses and other healthcare professionals by 

providing cues about the importance of ensuring patient safety 

along with other patient outcomes. The promotion of patient safety 

culture is a constellation of interventions targeted at minimizing 

patient harm. The various existing patient safety strategies are 

team training, interdisciplinary rounding or executive walk 

rounds, and unit-based strategies [7]. One among them is the 

medication reconciliation process.  

Medication reconciliation can be performed by clinical 

pharmacists or pharmacy technicians, electronic medical record 

tools, and patient-centered strategies. Studies have implied the 

emerging role of clinical pharmacists in a hospital setting where 

there have been instances in which patient medication histories are 

frequently recorded inaccurately by physicians during admission 

which results in medication-related errors and compromised 

patient safety [8]. Contributions from a clinical pharmacist to 

improvise patient outcomes can have a huge impact in the 

M 



Mandumpala                                                                                                                                       Medication reconciliation  

Vol 2 | Issue 1 | Jan – Mar 2023                                                                                             Indian J Pharm Drug Studies | 2  

healthcare field. Clinical pharmacists have ventured out of the 

pharmacy to ward round participation and in intensive care units 

[9]. Therefore, patient safety culture can be developed at the hands 

of a clinical pharmacists through the medication reconciliation 

process.  

Medication Reconciliation in Transitions of Care  

Transitions in care including admission and discharge from a 

hospital put a patient at risk for various aspects related to treatment 

from miscommunication to inadvertent information loss. Deficits 

in information transfer at hospital discharge can adversely affect 

patient safety. Possible interventions include computer-generated 

summaries and standardized formats that facilitate the timely and 

precise transfer of reliable patient information to physicians and 

make error-free discharge summaries [10]. Most of the transitions 

are unplanned, and often result from unanticipated or emergency 

medical problems that occur in during nights, weekends or any 

time of the day, involving physicians who may not have an 

ongoing relationship with the patient. Such transitions happen 

quickly and in a very short time frame which creates a barrier to a 

timely response from the formal and informal support systems 

[11].  

A study conducted by Forster et al reported that among the 

adverse events that occurred after the hospital half of them were 

preventable or ameliorable. This study important implications for 

quality improvement at the time of discharge. There is a need to 

follow patients more closely after discharge [12]. In alliance with 

the findings of the above study, a longitudinal multi-centre study 

conducted in a hospital examining the effectiveness of medication 

reconciliation at admission, discharge and post-discharge has 

come to similar conclusions. At admission, discharge and post-

discharge, changes in medication regimens were necessary for 

66.5%, 62.9% and 52.8% of patients, respectively during the 

medication reconciliation process [13].  

A recent meta-analysis conducted by Alemayehu et al has 

conclusively shown that pharmacist-led medication reconciliation 

programs have positive clinical outcomes at hospital transitions. 

They found a reduction in the rate of all cause readmissions (19%), 

all-cause emergency visits (28%) and ADE-related hospital visits 

(67%) [14]. This implies that a pharmacist can effectively target 

fragments of services across the entire spectrum of care transitions. 

Therefore, with consistent time and effort patient safety is 

achievable.  

Medication Reconciliation in Emergency Department  

Clinical pharmacy services such as medication reconciliation have 

immense benefits while identifying medication discrepancies and 

potential adverse drug events in the emergency departments. In a 

meta-analysis conducted by Chou et al the researchers concluded 

that a pharmacy-led medication reconciliation reduced the 

medication discrepancies by 68% in the emergency department. 

Similarly, patients with poly-pharmacy and comorbidities 

received marked benefits with a reduction in medical 

discrepancies at the hands of a pharmacy-led medication 

reconciliation [15].  

In another randomized controlled trial conducted in 2017, the 

authors analysed the improvement in admission medication 

reconciliation with pharmacists or pharmacy technicians in the 

emergency departments. As per the findings of the trial, it was 

found that pharmacists and pharmacy technician-led medication 

reconciliation in the emergency department reduced the admission 

medication history errors and admission medication order errors 

by over 80% [16]. Accurately documenting a patient’s home 

medications and allergies at the time of admission in an emergency 

department improves the efficiency and quality of patient care. 

The multiple benefits of employing a pharmacist-led medication 

reconciliation in the emergency department are as follows: 

Reduction in length of hospital stay, decreased future emergency 

room visits, reduction in drug-related admissions (such as adverse 

drug reaction, drug-related complication, hypersensitivity), 

decreased medication errors (especially the preventable ones), 

reduction in adverse events following drug administration, proper 

documentation of patient allergies, improved accuracy and 

completeness of patient profiles and most importantly cost-

effectiveness [17].  

Medication Reconciliation and Geriatric Care  

Medical care of the elderly is challenging work and is an essential 

part of the daily routine of a general practitioner. The older 

population is most often accompanied by multiple comorbidities, 

heavy prescriptions, complex medication regimens and above all 

polypharmacy. Moreover, decreased organ function and 

physiological reserves pose an exaggerated challenge in elderly 

care. While prescribing the clinician has to be extra cautious about 

the compromised pharmacokinetics due to ageing and the 

associated drug interactions. Implementation of clinical pharmacy 

services such as medication reconciliation, medication order 

review and discharge summary review minimizes the chance of 

exposing vulnerable population stratum to threats of medication 

errors [18]. Medication reconciliation involving therapeutic 

optimization is essential to ensure the safety of geriatric patients. 

However, its impact post discharge is hampered due to less or no 

recognition by general practitioners [19].  



Mandumpala                                                                                                                                       Medication reconciliation  

Vol 2 | Issue 1 | Jan – Mar 2023                                                                                             Indian J Pharm Drug Studies | 3  

Similarly, iatrogenic effects contribute largely to emergency 

admissions among elderly people. Clinical Pharmacists play a key 

role in reviewing and monitoring a patient's medication chart, this 

is an inevitable fragment of the medication reconciliation process. 

In a study conducted among geriatric patients by Beckett et al, 

there was a 23% improvement in the medication profile 

appropriateness when a pharmacist-led medication reconciliation 

was conducted within 24 hours of admission [20]. Therefore, 

targeting geriatric patients for medication reconciliation is of 

substantial benefit to both the healthcare system and the 

individual.  

Medication Reconciliation and Technology  

Electronic support can be a useful tool for improving the present 

scenario of the medication reconciliation process. To implement 

electronic support in the medication reconciliation process there is 

a need to have properly designed tools and a proper context for 

implementation [21]. However, there is a lack of scientific 

evidence for the impact of technology on identifying medication 

discrepancies during the medication reconciliation process. In a 

recent meta-analysis conducted in 2016, it was shown that 

electronic tools can reduce the incidence of medication 

discrepancies. As per the findings of this study, there was a 

reduction of 45% in medication discrepancies after the 

implementation of electronic tools for medication reconciliation 

[22]. In another randomized controlled trial, it was found that 

electronic medication reconciliation reduced adverse drug events, 

medication discrepancies and other adverse outcomes compared 

with usual care [23]. Therefore, it can be understood that enhanced 

electronic medication reconciliation systems within the hospital 

setting can be a useful strategy for improvising clinical pharmacy 

services.  

Role of Clinical Pharmacists in Medication Reconciliation  

Pharmacists are the most ideal candidates to conduct medication 

history interviews and reconcile medications as they are more 

aware of the drug names, characteristics, effects, dosage forms, 

administration, adverse drug profile, side effects and toxicity 

profile of drugs. An incomplete or inaccurate medication history 

may lead to compromised patient safety and pharmacists have the 

expertise and experience to scrutinize such errors and optimize a 

patient’s drug therapy through clinical interventions (Figure 1). 

The biomedical literature also indicates that pharmacist conducted 

medication reconciliation is more accurate, saves money, and 

increases patient safety [24–26].  

A study conducted in a tertiary care hospital in China has also 

revealed that medication reconciliation performed by pharmacist 

trainees can minimize unintentional medication discrepancies 

[27]. In another observational study conducted in Croatia, it was 

evidenced that clinical pharmacist-led medication reconciliation 

was an important tool in detecting medication discrepancies and 

preventing adverse patient outcomes [28]. Similarly, in a study 

conducted in Saudi Arabia, the researchers have concluded that 

medication reconciliation is crucial in reducing medication errors 

and pharmacists are the ideal resources to avoid medication-

related errors and the associated risks and complications [8].  

 

In alliance with the above findings, it can be suggested that not 

only pharmacists/ clinical pharmacists/ pharmacy technicians have 

a positive role in the medication reconciliation process but also 

pharmacy students. In a recent study conducted to analyse the 

benefits of employing pharmacy students in the medication 

reconciliation process, it was found that pharmacy students are a 

potential workforce solution. A particular finding from the study 

was that the fourth pharmacy students completed the best possible 

medication histories and identified discrepancies with prescribed 

medications for patients. Also, the pharmacy students were able to 

identify around 70% of medication discrepancies in the admitted 

patients during the medication reconciliation [29]. Therefore, 

pharmacy students can provide a beneficial service to the hospital 

by extrapolating their skills in clinical pharmacy services.  

CONCLUSION  

Medication reconciliation is an emerging tool to ensure patient 

safety in the hospital. It requires tremendous efforts from each 

healthcare professional to recognize treatment related harm. In 

such scenarios, a clinical pharmacist can contribute immensely 

and recognize errors or certain contributions in a way that can help 

improve patient outcomes. Medication reconciliation is 

particularly important when a geriatric patient is being admitted, 

with multiple comorbidities and the complex medication regimen, 

poly-pharmacy and non-adherence become an alarming threat. A 

similar situation arises in the emergency department and in the 



Mandumpala                                                                                                                                       Medication reconciliation  

Vol 2 | Issue 1 | Jan – Mar 2023                                                                                             Indian J Pharm Drug Studies | 4  

transitions of care where medications may go omitted or missed. 

Therefore, it is imperative to introduce timely patient safety tools 

to maintain the ongoing effort to achieve patient outcomes.  

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How to cite this article: Janice Jacson Mandumpala. 

Medication Reconciliation – A patient safety strategy. Indian J 

Pharm Drug Studies. 2023; 2(1) 1-4. 

Funding: None                        Conflict of Interest: None Stated 

 

https://www.jointcommission.org/resources/sentinelevent

