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What Is Medication Reconciliation? - Definition & Process

Instructor: Lynee Carter
In this lesson you will learn five steps in medication reconciliation, the medical professionals who use the process and why it is important to follow for patient safety.

Introduction

Anyone working in the medical field can tell you that administrating medications is one of the most dangerous things done in the profession. You have probably heard about hospital medication errors that have harmed patients. Some have even led to death! This is why there is a process to help ensure patients receive the right medications while being cared for at healthcare facilities.

What is Medication Reconciliation?

Medication reconciliation is the process where medications prescribed by a medical practitioner are checked to ensure they match the current list of medications the patient is taking. Depending on the healthcare facility, this is accomplished in different ways. Most require it whenever a patient is admitted, transferred and discharged. In each situation they strive for the same goal which is to avoid all types of medications errors that can negatively effect their patients.

Here are some common mistakes that can be made:

  • Medications can be accidentally listed multiple times or not at all.
  • Some drugs can be listed that patients never have taken before or their medical practitioner never prescribed.
  • Medications can also have the wrong dose, route, frequency and time.
  • In some cases they may not be appropriate for the patient due to drug allergies or they are irrelevant to the patient's current situation.

From any of these mistakes, the patients can end up taking the wrong medication or not receiving the right drug they need to take care of their health condition.

The Process

Step 1: Obtaining the Patient List of Medications

One of the first questions you ask a patient when they come to a healthcare facility is for the list of medications they are taking. If you're a doctor, you need to know all the medications they take which can include prescriptions, over-the-counters, herbal supplements, and vitamins. The patient may not have a paper copy but can recall them all to you. Some patients will be able to tell you all the details you will need to know such as the name, dose and frequency.

Other patients will only know a limited amount of information. You may hear things like, I take that little white pill twice a day or I take that medication that begins with a 'C' for my heart. In these cases, it's best to obtain the list from a reliable source. This could be the patient's family member or provider who cares for the patient at home. It may also mean contacting the patient's pharmacy, doctor's office or residential facility. Regardless of how the list is obtained, it's important to make every effort to get an accurate one.

med list

Step 2: Developing the Prescribed List of Medications

Medical practitioners are responsible for prescribing the medications they want the patients under their care to take. They review health records to obtain information about the medications the patient is taking that have been documented from previous visits to health care facilities. Some get a list from the patient directly or receive one from another medical professional.

The prescribed list can then be developed by using the same medications found in the health history. In some cases, the medical practitioner may need to add, remove or modify certain drugs based on the patient's condition. These changes would also go on the new list that is recorded on paper or in a computer system called the electronic health record. By doing this it points out the specific medications the medical practitioner wants the patient to take.

medical records

Step 3: Comparing Both Lists

Then the list obtained from the patient and the list the medical practitioner prescribed are thoroughly examined. Each medication is individually checked to see that it's written the same way on both lists. If there is a medication that does not match, something is missing or it's unclear overall, it's brought to the attention of the medical practitioner. Many potential medication errors can be avoided at this step when differences are identified.

Check out these examples:

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