Amy Stewart, RNIn an ideal state of care delivery, medical information would follow each patient as he or she transitions from one care setting to another. In reality, care coordination is often fragmented, leaving the patient vulnerable to adverse events (injuries resulting from medical management rather than from an underlying disease process).
Medication-related adverse events in particular occur more frequently during transitions of care, although they are often preventable. Consistent use of a medication-reconciliation process decreases the risk for medication-related adverse events, thereby preventing many hospital readmissions and emergency room visits.
As the government moves toward a value-based pay-for-performance system, whereby providers are penalized for poor patient outcomes and increased patient costs, it is imperative for providers to consider how they reconcile patient medications at times of admission, transfer, and discharge.

Starting the Process

Medication reconciliation, according to the Joint Commission, involves comparing medications a patient is taking and should be taking with newly ordered medications in order to identify and resolve discrepancies. The goal is to obtain the most accurate list possible of all the patient’s medications.
The process involves:
  • Reviewing the patient’s current list of prescription and over-the-counter medications at the time of admission, transfer, or discharge;
  • Comparing the patient’s current medication list with the most recent home-medication list;
  • Verifying that the patient’s home and current lists of medications have no unintended discrepancies (those that are not supported by the patient’s clinical condition);
  • Communicating any discrepancies to the prescriber (physician or physician extender if allowable);
  • Obtaining clarification orders if needed; and
  •  Developing a patient medication profile that can be used to show current and previous medication changes that occurred while the patient was in the skilled nursing center, which can be given to the patient and shared with his or her primary care physician upon discharge.

Future Reg To Require Reporting

Beginning in October 2018, the Centers for Medicare & Medicaid Services (CMS) will implement a new skilled nursing facility (SNF) quality reporting program (QRP) measure related to medication reconciliation and physician follow-up for Medicare Part A residents.

According to section 3 of CMS’ Proposed Measure Specifications for Measures Proposed in the FY 2017 SNF QRP NPRM, released April 2016, the Quality Measures data will be captured on the Minimum Data Set through additional questions in section N beginning Oct. 1, 2018. This information will be used as part of FY 2020 payment determinations.

The measure reports the percentage of resident stays in which a drug regimen review was conducted at the time of admission and timely follow-up with a physician occurred each time a potentially clinically significant medication issue was identified during the stay.

Although the QRP measure related to medication reconciliation does not take effect until October 2018, reconciling medications during transitions of care improves patient safety by lowering the risk of unidentified discrepancies. The risk for medication-related adverse events is higher in elderly patients who have multiple chronic diseases and thus multiple medications. Implementing a medication-reconciliation process will improve patient safety, improve outcomes, and decrease health care costs.

The quality assurance and performance improvement (QAPI) committee meeting is the ideal venue for reviewing the facility’s current medication-reconciliation process and monitoring for improvement opportunities. If a process is not in place, the QAPI committee may want to consider a Performance Improvement Project (PIP) charter whose focus is on establishing a process for medication reconciliation during each transition-of-care episode.

CMS offers free resources and tools, including a worksheet, for creating a PIP charter. This worksheet helps to establish goals, scope, timing, milestones, and team roles and responsibilities for the improvement project. There are also resources available to assist with goal setting and monitoring progress toward goals.

Draw Up Checklist

Once the PIP team is established, team members should begin by creating a flowchart of the current medication-reconciliation process upon admission, readmission, transfer, and discharge. The team should look for improvement opportunities as well as verify that the process in place meets the definition of a sufficient medication-reconciliation process.
For starters, does the current process identify/include the following:
  • The person responsible for the initial medication-reconciliation review;
  • The time frame in which medication reconciliation is to be completed;
  • Where the process will be documented as completed;
  • Discrepancies such as omissions of any medications;
  • Different doses or frequencies of medications that require investigation;
  • Multiple medications within the same therapeutic class;
  • Medications that are inconsistent with the patient’s current clinical status;
  • The time frame in which a physician is to be notified if any discrepancies are found;
  • An indication that discrepancies have been reviewed by a physician and orders modified;
  • Patient or family interviews related to medication history and previous home medications;
  • A systematic review to ensure medication reconciliation was completed at each transition of care;
  • Ongoing staff education on the importance of medication reconciliation;
  • A process for reporting to the QAPI committee regarding the percentage of discrepancies found for a given time frame;
  • An examination of possible trends identified related to the discrepancies (for example, a number of discrepancies coming from a particular acute-care hospital or physician); and
  • Completion of a master medication list as a result of the process.
Next, the team will review the medication-reconciliation process for redundancies, barriers, and feasibility. An example of a barrier might be the majority of patients being admitted on evenings and weekends when there are fewer staff, making medication reconciliation more difficult to complete. The team will want to consider strategies to overcome such a barrier.
■ Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. (Prepared by the Island Peer Review Organization under Contract No. HHSA2902009000 13C.) AHRQ Publication No. 11(12)-0059. Rockville, MD: Agency for Healthcare Research and Quality. Revised August 2012.
■ Institute for Healthcare Improvement. Medication Reconciliation to Prevent Adverse Drug Events. Retrieved from:

Check Resources

The team will also want to look at any resources needed to ensure the successful rollout or improvement of the medication-reconciliation process.
For example, improving the process of obtaining a complete patient history may require facility staff to build a new form in their electronic health record, but they may not have either the physical or financial resources to do so. Therefore, the team may need to go back to leadership to obtain approval for such items or look for opportunities that are within the organization’s physical and financial means.
Once a review of the process is completed, staff members who participate in the medication-reconciliation process will need to be educated on any changes and made aware of their responsibility in the process.
Physicians and physician extenders will also require education on changes, including any expectations to follow up within a given time frame.
Staff must continue to monitor the success of the medication-reconciliation process and report findings to the QAPI committee.
A solid medication-reconciliation process improves patient safety by decreasing the risk for adverse drug events. As payment initiatives increasingly seek to base pay on outcomes and on quality rather than quantity of care delivered, it is more important than ever to have sound processes in place to ensure that residents remain safe and avoid preventable hospital readmissions or emergency room visits.
Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, is curriculum development specialist for the American Association of Directors of Nursing Services (AADNS). She can be reached at