Medication History Guidelines for Medication Reconciliation
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Best Possible Medication History Guidelines for Medication Reconciliation
March 2007

Acknowledgement: Input from ISMP Canada to this document was gratefully received.

Discrepancies in patients’ medications after transitions in care from one setting to another are responsible for a large number of adverse events for patients. For example, patients who are discharged from hospital have a high risk of adverse drug events due to medication discrepancies as they transition to the community. Forster et al revealed that 23% of patients discharged from a Canadian teaching hospital experienced an adverse event, of which 72% were drug related.1

Another study identified unexplained discrepancies between preadmission medications and discharge orders for 49% of patients.2

Medication discrepancies can occur as patients are admitted from community into an institutional setting. Approximately 50% of patients have at least one unintentional medication discrepancy in their hospital admission orders.3

Medication discrepancies can also occur as patients are moved from one level of care to another within institutions or in the community (e.g. home care) or when patients are referred to other physicians for part of their care.

The discovery of discrepancies can prevent adverse drug events and may be an indication for a possible intervention in the form of a Medication Consultation.

Principles:

Medication Reconciliation is a process that requires a comparison of what the physician ordered versus what the patient is taking. The goals of medication reconciliation are:

  • Provision and maintenance of an accurate and current record (best possible medication history) of what medications a patient is taking
  • Correction of discrepancies between physician orders and what is being taken
  • Prevent of adverse events and potential patient harm).
This process may be effective in preventing medication errors, whether it is in transition from hospital to community or vice versa.

Pharmacists are the key health care providers for dealing with patient’s medications. It is important that pharmacists collaborate with each other, other health care providers, and their patients to prevent errors and promote safe health care. This is further strengthened by the Personal Health Information Protection Act, 2004 (PHIPA) implied consent model which acknowledges that pharmacists are considered to be within the “circle of care” when providing direct health care and are permitted to rely on an individual’s implied consent for the collection, use and disclosure of personal health information.

Process:
  1. The pharmacist creates the patient’s best possible medication history (BPMH) through interview of patient, family and/or other healthcare practitioners, on-site profile documentation, transferring documentation if available and observation of drug containers when available.
  2. The pharmacist compares the BPMH and the physician’s current orders, with the goal of identifying, preventing, and resolving drug related problems (DRPs).
  3. The pharmacist documents discrepancies between the BPMH and the physician’s orders, whether they are intentional or unintentional.
  4. The pharmacist contacts the ordering prescriber and reconciles medications within a specified time frame.
  5. The pharmacist communicates all of this information in a clear and concise form to the next health care provider and patient.
  6. A pharmacist who is aware of a patient’s planned visit to another point of care facilitates a Medication Reconciliation with the patient within the two weeks prior to the transition and provides documentation to the patient and the next health care provider.

Definitions:

“Intentional discrepancy” is a discrepancy between the BPMH and the physician’s orders in which the physician has made an intentional choice to add, change, or discontinue a medication and the choice is clearly documented.

“Undocumented intentional discrepancy” is a discrepancy between the BPMH and the physician’s orders in which the physician has made an intentional choice to add, change, or stop a medication, but the reason is not clear and there is no documentation.

“Unintentional discrepancy” is a discrepancy between the BPMH and the physician’s orders in which the physician unintentionally changed, added, or omitted a medication the patient was taking previously and there is no documentation. This may occur especially when directions regarding the management of preadmission medications is omitted or not explicitly documented on patient discharge.

BPMH Requirements:
  • The BPMH includes all current and relevant past prescription medications, non-prescription medications, and complimentary/alternative medications (CAMs).
  • Included for each medication or product is dose, dosage form, frequency, route, indication, level of patient adherence, and the source of the information.
  • In order to obtain and record information for the BPMH the pharmacist consults all relevant sources of information including, but not limited to, the patient, patient’s family, medication packages/vials, primary care provider, specialists, and sending pharmacist.

Patient Selection:

In order to have the greatest impact, the pharmacist identifies patients within their practice who are on multiple medications, have had frequent medication changes, are on medications with narrow therapeutic indices, such as warfarin or digoxin, are on high alert medications such as opiates, are confused about their medications, or have special needs such as paediatric patients or the frail elderly.

Best Possible Medication History Form:

To assist the pharmacist in relaying the patient’s information in a clear and concise manner, a number of forms are available for use. These can be accessed free of charge at the Safer Health Care Now! (SHN) Website www.saferhealthcarenow.ca under The Six Interventions and then MedRec.
(See below for a sample of the Best Possible Medication History Form)

Pharmacists who wish to design their own forms may chose to include the following information:
  • Patient’s name, address, phone number, and identification number
  • Known allergies
  • Family physician information
  • Community pharmacy information
  • Area for BPMH (see above)
  • Area for recording comments about intentional or unintentional medication discrepancies.
    Click Here to download the form in Word format, which you can edit to suit your purposes
    Click Here to download the form in printable PDF format

1Forster AJ. Murff HJ. Peterson JF et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003; 138: 161-7.
2Schnipper JL, et al Role of Pharmacist Counseling in Preventing Adverse Drug Events After Hospitalization, Arch Intern Med. 2006; 166:565 - 571
3Tam 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(5): 510-5.