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Pharmacist Medication Reconciliation

January 31, 2008 2:22 PM | Brad Miller (Administrator)

In the February WMSHP Newsletter, Chelsey Skiba, a Ferris State University Pharm.D. Candidate, writes of the benefits of pharmacists performing medication reconciliation.


Are pharmacists more effective at promoting patient safety by performing medication reconciliation compared to other healthcare professionals?

Evidence Based Answer
Evidence suggests that pharmacists do promote patient safety by performing medication reconciliation more effectively than other health care professionals (Strength of Recommendation [SOR]: C-, based on six pilot studies). Pharmacists performed more complete medication histories by identifying a higher average of home mediations per patient than other health care professionals (SOR: C-, based on four pilot studies). Pharmacists identified more discrepancies between home medication orders and medication histories than nurses (SOR: C-, based on two pilot studies).

Evidence Summary
An accurate and complete medication history is important because if it is incorrect it can lead to inappropriate drug treatment. According to a pilot study carried out by Nester and Hale, patients who had a pharmacist take their medication histories rather than a nurse received a significantly larger fraction of clinical interventions (34% vs. 16%, p<0.001). It was also found that nurses had significantly fewer patients noted as taking a herbal/nonprescription medication than the pharmacists (70% vs. 98%, p<0.001). Patients' community pharmacies were also contacted significantly more often by pharmacists than by nurses for clarification (24% vs. 4%, p<0.001).1 Nester concluded that pharmacists are more effective at taking medication histories than nurses, but a small sample size and representation are limitations to this study.

In a pilot study performed by Gleason et al, pharmacists conducted medication histories and reconciled the information received with the patients chart history, which was first obtained by doctors and nurses. When a medication discrepancy was noted between the two histories the pharmacist would alert the doctor and if the doctor acted on the discrepancy it was defined as an error and was then accessed for its potential to have caused patient harm. Physicians adhered to pharmacists suggestions about the discrepancies the bulk of the time (n = 69/97 or 71%). Complete omission of a drug that a patient was on prior to hospitalization was the discrepancy requiring intervention most frequently (n= 41/97 or 42%). The authors then used the National Coordinating Council for Medication Error Reporting and Prevention's (NCCMERP) 9-point rating scale to determine potential patient harm if the intervention had not been made in the first 24-48 hours of admission. They noted 38/69 (55%) of the discrepancies fell into the least likely to cause harm category (A-C). On the contrary, if 15/69 (22%) of the discrepancies had not been intervened by a pharmacist the patient outcome could have resulted in harm (categories E & F).2 Gleason concluded that medication reconciliation by a pharmacist may have prevented patient harm, but this is up to interpretation due to the descriptive nature of their statistics. Lessard et al performed a similar study to describe medication discrepancies in senior patients and found that the majority (57%) of the discrepancies noted were omissions also. They used a modified version of the NCCMERP and found that a portion (25.8%) of the discrepancies fell into the category that could have necessitated monitoring and/or intervention to prevent harm (category D).3

A pilot study completed in a hospital's inpatient behavioral health unit comparing nurse and pharmacist obtained medication histories found that pharmacists identified a significantly higher average number of medications per patient than nurses (5.3 vs. 4.0, p<0.05).4 A pilot study carried out in a hospital Emergency Department (ED) had 252 patients complete medication histories by an ED provider and then by a pharmacist. ED providers only identified 817 home medications from the same patients that pharmacists identified 1096 home medications.5 Another study in the ED compared the effect a pharmacist had on a hospitals medication reconciliation form that was usually filled out by a nurse and found that pharmacists had significantly less errors upon completion of the form than the nurses (3% vs. 59%, p = 0.001). The nurses also recorded significantly less allergy documentation than the pharmacists (79% vs. 100%, p = 0.001).6

Author Comments
The 2008 National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) necessitate that "medications are accurately and completely reconciled across the continuum of care." JCAHO rational stated that medication reconciliation is "essential in the reduction of transition related adverse drug effects."7 Although JCAHO does not recommend a specific health care professional be responsible for medication reconciliation the American Pharmacists Association recommends that "pharmacists be responsible for reconciling medication use when patients move between practice settings within the continuum of care".8 The American Society of Health-Systems Pharmacists set a goal for their 2015 initiative for pharmacists to be "involved in managing the acquisition, upon admission, of medication histories for the majority of inpatients with complex and high-risk medications in 75% of hospitals".9


  1. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Ann J Health-Syst Pharm. 2002;59(22):2221-25.
  2. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitilzed patients. Am J Health-Syst Pharm. 2004;61(16):1689-95.
  3. Lessard S, DeYoung J, Vazzana N. Medication discrepancies affecting senior patients at hospital admissions. Am J Health-Syst Pharm. 2006;63(8):740-3.
  4. Lizer MH, Brackbill ML. Medication history reconciliation by pharmacists in an inpatient behavioral health unit. Am J Health-Syst Pharm. 2007;64(10):1087-91.
  5. Carter MK, Allin DM, Scott LA, Grauer D. Pharmacist-acquired medication histories in a university hospital emergency department. 2006;63(24):2500-2503.
  6. Hayes BD, Donovan JL, Smith BS, Hartman CA. Pharmacist-conducted medication reconciliation in an emergency department. 2007;64(16):1720-3.
  7. Joint Commission on Accrediation of Healthcare Organizations. 2008 National Patient Safety Goals.http://www.jointcommission.org/NR/rdonlyres/82B717D8-B16A-4442-AD00-CE3188C2F00A/0/08_HAP_NPSGs_Master.pdf (accessed 2007 Sept 24).
  8. American Pharmacists Association. Final Report of the 2007 APhA House of Delegates.http://www.pharmacist.com/AM/Template.cfm?Section=Search1&section=About_APhA1&template=/CM/ContentDisplay.cfm&ContentFileID=3311 (accessed 2007 Sept 24).
  9. American Society of Health-Systems Pharmacists. 2015 Health-System Pharmacy Initiative. http://www.ashp.org/s_ashp/docs/files/2015_Goals_Status_0307.pdf 
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