Skip to content

Pharmacy-Led Medication Reconciliation

Medication errors represent the most common patient safety issue in hospitals today, with the average hospitalized patient subjected to roughly one medication error per day. More than 40 percent of these errors are believed to be the result of inadequate reconciliation in handoffs between admission, transfer and discharge, with 20 percent of those errors resulting in harm.

Prior to implementing the new initiative, medication reconciliation at Beaufort Memorial Hospital was primarily the nurses’ responsibility. Due to the high demands placed on nursing staff, details were often overlooked or missed entirely while compiling a patient medication history. The list then was entered into the EHR by the physician and reviewed by a pharmacist.

The Goal:
Reduce medication errors by placing a trained pharmacist or pharmacy technician in charge of the medication list at each stage of the process (admission, transfers, discharge) to prevent mistakes in the medical record and during medication reconciliation.

Method & Implementation:
Set up a medication reconciliation team (three pharmacists and one technician at Beaufort Memorial) who will see all patients within 24 hours of being admitted to the hospital. The team is housed in the emergency department, allowing patients to be seen as soon as they are deemed eligible for admission by the emergency department physician. The team gathers data through interviews, retail/mail order history, primary care office records, patient prescriptions, insurance billing history and a controlled substance monitoring system.

In phase two, patients who are prescribed high-risk medications are seen by a pharmacist or pharmacy technician at discharge as well. A complete medication list is provided to the patient and prior authorizations are completed before the patient leaves the hospital. Patients are provided education on the new medication by the pharmacist.

Challenges & Barriers:
Getting buy-in from hospital administration to hire the necessary pharmacy staff
Educating nurses and doctors about new procedures to avoid duplicate efforts
Having pharmacy staff fully available for all admissions and discharges
Identifying qualified pharmacy technicians

A clear process and department delineated roles, reduced work for all providers, and increased physician and nurse satisfaction
Hired pharmacists from the community because they have worked with a larger formulary and with multiple providers
Errors in active medication lists dropped from 34% to 2%

Return on Investment:
The pharmacy believed an estimated 85% of medication errors would be avoided, with a predicted cost avoidance of $153.30 per pharmacy intervention, which translated to $3,833 per day and more than $500,000 annually.

For more information about this story or to tell us about your own best practices, email us at

References to Support Work:
Gleason KM, Brake H, Agramonte V, Perfetti C. Medications and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. AHRQ publication No. 11(12)-0059. Rockville, MD: Agency for Healthcare Research and Quality. Revised August 2012. Available at

Gillespie U, Alassaad A, Henrohn D, et al. A Comprehensive Pharmacist Intervention to Reduce Morbidity in Patients 80 Years or Older. Arch Intern Med. 2009;169:894-900.

Hart C, Price P, Graziose G, et al. A Program Using Pharmacy Technicians to Collect Medication Histories in the Emergency Department. P&T 2015;40:56-61.

Johnson JA, Bootman JL. Drug-related morbidity and mortality: a cost-of-illness model. Arch Intern Med. 1995;155:1949-1956.

Kwan JL, Lo L, Sampson M, Shojania KG. Medication Reconciliation during Transitions of Care as a Patient Safety Strategy: A Systematic Review. Ann Intern Med. 2013;158:397-403.

Meguerditchian AN, Kroteneva S, Reidel K, Huang A, Tamblyn R. Medication Reconciliation at Admission and Discharge: a Time and Motion Study. BMC Health Services Research 2013, 13:485

Schnipper JL, Kirwin JL, Cotugono MD, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006 Mar 13;166(5):565-71.

Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173:510-5.

Warden BA, Freels JP, Furuno JP,et al. Pharmacy-managed program for providing education and discharge instructions for patients with heart failure. Am J Health Syst Pharm. 2014 71:134-139

Whitty JA, Green B, Cottrell WN. A study to determine the importance of ward pharmacists reviewing discharge prescriptions. Aust J Hosp Pharm 2001;31: 300-2.

Yun Lu, Pamela Clifford, Andreas Bjorneby, et al. Quality improvement through implementation of discharge order reconciliation Am J Health Syst Pharm May 1, 2013 70:815-820.