CHPPC Module 14, Section 2: Medication Reconciliation Touchpoints
MODULE 14: BEDSIDE PHARMACIST SAFETY ROUNDS

Section 2: Medication Reconciliation Touchpoints

Welcome to a masterclass on what is arguably the single most impactful activity a hospital pharmacist can perform to prevent medication errors. Medication reconciliation is not simply the act of creating a list; it is a high-stakes, investigative, and cognitive process of ensuring accuracy and continuity of care at the most vulnerable points in a patient’s hospital journey. In this section, you will learn how to leverage your existing expertise in medication history taking and translate it to the dynamic hospital environment. We will explore how your physical presence at the bedside enhances this process at the critical transitions—admission, transfer, and discharge—helping you resolve discrepancies and prevent harm by speaking directly with the patient, family, and nurse.

2.1 The Med Rec Imperative: A National Patient Safety Goal

Understanding why this process is at the heart of medication safety.

Medication reconciliation is defined by The Joint Commission as the process of “comparing the medications a patient is taking (and should be taking) with newly ordered medications” to identify and resolve discrepancies. This seemingly simple administrative task is, in fact, a complex clinical endeavor that is consistently ranked as a top National Patient Safety Goal. Why? Because studies have shown that up to 50% of all medication errors and 20% of adverse drug events in hospitals can be attributed to inadequate medication reconciliation. These errors are most likely to occur at “transitions of care”—the very moments when a patient’s care is handed off from one setting or provider to another.

Retail Pharmacist Analogy: The New Patient Profile Build

When a new patient comes to your pharmacy with prescriptions from three different doctors, you don’t just fill them blindly. You perform a mini-med rec on the spot. You meticulously build their profile, entering all their known drugs. Your mind immediately starts looking for discrepancies. “Mrs. Jones, I see Dr. Smith prescribed lisinopril, but you mentioned you were also taking losartan from Dr. Davis. Are you taking both?” In that moment, you’ve identified a major therapeutic duplication. You then act as an investigator, calling the patient or prescribers to determine the single, correct list of medications. You are creating a “single source of truth” for that patient’s profile in your system.

This is the exact goal of hospital-based medication reconciliation, but on a grander scale. The hospital admission is the “new patient” encounter. The prescribers are the multiple teams of hospitalists, specialists, and surgeons. And you, the pharmacist, are the ultimate investigator, tasked with creating the one and only “single source of truth” for the patient’s medications, which will be the foundation for their entire hospital stay.

2.1.1 The Three Critical Touchpoints

While med rec should be an ongoing process, there are three specific, high-risk transition points where a formal, pharmacist-led reconciliation has the greatest impact. Your bedside rounding workflow should be designed to prioritize these events.

1. Admission: The Foundation

This is the most important reconciliation. The list created upon admission becomes the basis for all subsequent inpatient orders. An error made here (e.g., omitting a crucial home medication) will be perpetuated throughout the entire hospital stay and can lead to significant harm.

2. Internal Transfer: The Handoff

When a patient moves from one level of care to another (e.g., from the ICU to the medical floor), their medication needs change dramatically. This handoff is a prime opportunity for errors of omission or commission if the medication orders are not carefully reconciled against the patient’s changing clinical status.

3. Discharge: The Safe Landing

The final reconciliation before the patient leaves the hospital. This process determines which inpatient medications are stopped, which home medications are resumed, and which new medications are started. Errors here can lead to confusion, non-adherence, and preventable readmissions.

2.2 The Admission Touchpoint: A Masterclass on the Best Possible Medication History (BPMH)

Your role as a clinical detective in creating the single source of truth.

The foundation of all safe inpatient medication use is the Best Possible Medication History (BPMH). This is not simply a list of what the patient says they are taking. It is a meticulously researched, verified, and documented history that has been cross-referenced against multiple sources to be as accurate as humanly possible. While this task is sometimes performed by nurses or physicians, studies have overwhelmingly shown that pharmacist-led BPMHs are the gold standard, catching significantly more errors. Your expertise in drug names, doses, and your investigative mindset make you uniquely qualified for this role.

2.2.1 The Multi-Source Investigation

Creating a true BPMH requires you to be a detective, gathering clues from multiple sources and looking for corroborating evidence. Relying on a single source is a recipe for error.

Source Strengths Weaknesses / Pitfalls
The Patient Interview The primary source. Provides information on adherence (“I only take my lisinopril when my head hurts”), OTC/herbal use, and the “why” behind their regimen. Memory can be unreliable, especially in elderly or acutely ill patients. Health literacy may be low. Patients may not consider eye drops or inhalers to be “meds.”
Family/Caregiver Interview Often more reliable for patients with cognitive impairment. Can provide crucial details about how medications are actually administered at home. May not be present or available. May also have an incomplete picture if they are not the primary caregiver.
Patient’s Own Pill Bottles “Ground truth.” Provides the exact drug, dose, pharmacy, and fill date. An invaluable source to have at the bedside. Patients rarely bring all their bottles. The directions on the label may not reflect how the patient actually takes the medication (e.g., “doctor told me to cut them in half”).
Outpatient Pharmacy Records Provides an objective, dated fill history. Can reveal non-adherence (e.g., a 30-day supply of a maintenance med was last filled 3 months ago). Your retail background makes you an expert at interpreting this data. Patients may use multiple pharmacies (retail, mail-order). Does not include samples from the doctor’s office. A filled prescription doesn’t guarantee the patient is actually taking it.
PBM/Surescripts Data Provides a consolidated view of claims data from multiple pharmacies. Good for identifying the use of different pharmacies. Data can have significant lag time. Does not include medications paid for with cash or on a discount card that bypasses insurance.
Previous Hospital Records The discharge summary from a previous admission can provide a professionally reconciled medication list at that point in time. The list is only as good as the last reconciliation. The patient’s PCP could have made multiple changes since the last discharge.

The Art of the Patient Interview: A Pharmacist’s Guide

Your bedside presence allows you to conduct the most valuable part of the BPMH: the patient interview. This is a skill. It’s more than just reading a list. It’s a conversation designed to elicit accurate information.

  • Start with an Open-Ended “Show and Tell”: Don’t start with “Are you taking lisinopril?”. Start with “Please tell me about all the medications you take at home. Let’s start with the morning.” Let the patient tell their story.
  • Use Probing Questions for Each Med: For each drug they mention, dig deeper.
    • “What is that medication for?” (Assesses understanding)
    • “How many milligrams is the tablet?” (Assesses knowledge of strength)
    • “How many times a day do you actually take it?” (Assesses adherence vs. prescribed sig)
    • “When was the last time you took a dose of that?” (Critical for NTI drugs like warfarin)
  • Don’t Forget the “Non-Meds”: Specifically ask about things patients often forget.
    • “Do you use any inhalers, eye drops, ear drops, or creams?”
    • “Do you take anything over-the-counter, like for pain or allergies?” (Ask for Tylenol, Advil, Zyrtec by name).
    • “Do you take any vitamins, supplements, or herbal remedies?”
  • The Power of “Why Not?”: If you see a maintenance medication on their pharmacy fill list but they don’t mention it, ask about it directly. “I see from your pharmacy records that you filled Lipitor last month. Are you still taking that one?” If they say no, the follow-up is key: “Can you tell me why you stopped taking it?” The answer may reveal a critical adverse effect or a cost barrier.

2.3 The Internal Transfer Touchpoint: Bridging the Gaps in Care

Ensuring a safe handoff as a patient’s level of care changes.

While admission and discharge are the most recognized transition points, internal transfers are a hidden source of significant medication errors. When a patient moves from a general medical floor to the ICU, or vice versa, their entire clinical picture changes. The medications appropriate for a critically ill patient on a ventilator are often dangerous for a stable patient on the floor. This handoff between medical teams and nurses is a critical moment where a pharmacist’s review of the medication orders is essential to ensure they are still appropriate for the patient’s new clinical status and location.

2.3.1 Common Errors at Internal Transfer

Your proactive profile review should be laser-focused on identifying these common pitfalls:

  • Continuation of ICU Drips on the Floor: A patient may be transferred from the ICU with an order for a continuous insulin or vasopressor infusion still active. General medical floors are not staffed or equipped to safely manage these high-risk infusions. This is a “never event” and you must ensure these orders are discontinued *before* the patient leaves the ICU.
  • Failure to Resume Home Medications: During the acute phase in the ICU, many of a patient’s home medications (e.g., statins, antidepressants) may have been held. When they transfer to the floor and stabilize, these medications need to be systematically reviewed and resumed. Forgetting to restart a patient’s home anti-epileptic drug could be catastrophic.
  • Dosing Discrepancies: Dosing protocols can differ between units. For example, the ICU may use a more aggressive sliding scale insulin protocol than the medical floor. You must ensure the patient is transitioned to the appropriate protocol for their new location.
  • Loss of Prophylaxis: Orders for VTE or SUP prophylaxis can easily get dropped during the transfer process. You must re-evaluate the need for these preventative therapies based on the patient’s current status.

The Pharmacist’s Transfer Reconciliation Workflow

As soon as you are notified that one of your patients is transferring, you should initiate this proactive safety review.

  1. Review the Current MAR vs. the Admission BPMH: Pull up two lists side-by-side. What is the patient currently on? What were they on at home? Identify all the home medications that are currently on hold.
  2. Review All Continuous Infusions: Are there any active drips that are inappropriate for the receiving unit? Flag these immediately.
  3. Create a “To-Do” List: Based on your review, create a list of recommendations for the transferring physician.
    • “Discontinue insulin drip upon transfer.”
    • “Resume home atorvastatin 40mg daily.”
    • “Resume home levetiracetam 500mg BID.”
    • “Change sliding scale to standard floor protocol.”
  4. Communicate Proactively: Don’t wait for the provider to make a mistake. Contact them before they write the transfer orders. “Dr. Smith, I see you are planning to transfer Mr. Jones to the floor. I’ve reviewed his medications. To ensure a safe transfer, we’ll need to discontinue the insulin drip and I recommend we resume his home atorvastatin and levetiracetam. Would you like me to pend those orders for you?”
  5. The Bedside Handoff: When the patient arrives on the new unit, your rounding process is crucial. You can physically go to the room, introduce yourself to the new nurse, review the new MAR with them, and verify that the pump for any new infusions is programmed correctly.

2.4 The Discharge Touchpoint: A Masterclass on the Safe Landing

Your role as the final quality check and patient educator.

The discharge medication reconciliation is the final, critical handoff from the controlled hospital environment back to the patient. This is the moment where your skills as a community pharmacist are most directly translatable and most valuable. You are the expert in patient counseling, identifying barriers to adherence, and navigating the complexities of outpatient prescriptions. Your primary goal at discharge is to prevent the confusion that leads to non-adherence and preventable hospital readmissions. Your bedside presence transforms this from a paper-based process into a hands-on, educational encounter.

2.4.1 The Three Steps of Discharge Reconciliation

A safe discharge is a three-step process: Reconcile, Prescribe, and Educate.

  1. Step 1: Reconcile the Lists. This is a cognitive task you perform in the EHR. You must compare three lists side-by-side:
    • The patient’s pre-admission home medication list (the BPMH).
    • The patient’s current inpatient medication list.
    • The provider’s proposed discharge medication list.
    Your job is to ensure every medication is intentionally accounted for. Was a home med stopped? Why? Was a new inpatient med added? Should it be continued? You are the final check for omissions, duplications, and errors.
  2. Step 2: Facilitate the Prescriptions. Once the list is finalized, you must ensure the patient has a viable way to obtain the medications. This is your retail expertise in action. Does the new anticoagulant require a prior authorization? Does the patient’s insurance cover the new brand-name inhaler? Is the patient being discharged with a small supply from the hospital (“meds to beds”) or with prescriptions sent to their community pharmacy? You are the logistics manager ensuring a smooth transition.
  3. Step 3: Educate the Patient and Family. This is the most important step and where your bedside presence is irreplaceable. You must provide clear, concise counseling on the finalized discharge medication list.

A Masterclass on Bedside Discharge Counseling: The “Teach-Back” Method

Effective counseling is not a lecture; it is a conversation that confirms understanding. The Teach-Back method is the gold standard for this.

The Wrong Way (Lecture): “Okay Mrs. Jones, you’re going home on three new medicines. This is Eliquis 5mg twice a day for your blood clot, this is metoprolol 25mg twice a day for your heart rate, and this is lisinopril 10mg once a day for your blood pressure. Do you have any questions?” (The patient, overwhelmed, will almost always say “no.”)

The Right Way (Teach-Back):

  1. Introduce the purpose: “Mrs. Jones, we’re starting a few new medicines to keep you safe when you go home. It’s really important we go over them to make sure I’ve explained everything clearly.”
  2. Focus on 2-3 key points per drug: Go through each new medication one by one. Hold up the vial or a picture of the pill.
    “This is your new blood thinner, called Eliquis. We are giving this to you to treat the blood clot that was found in your leg. You will take one tablet in the morning and one tablet in the evening. Because this is a blood thinner, the main side effect we need to watch for is bleeding. So, you’ll want to be careful to avoid falls.”
  3. Ask the patient to “Teach Back”: This is the crucial step. Frame it as a test of your explanation, not their memory.
    “Just to make sure I did a good job explaining, can you tell me in your own words what this new medicine is for?”
    “And how many times a day will you be taking it?”
    “What is the main side effect we talked about watching out for?”
  4. Review the Changes: Clearly state which medicines were stopped. “Remember, we are stopping your home ibuprofen. We don’t want you to take that with the Eliquis.”
  5. Provide a Written List: Give the patient a clear, printed list of all their discharge medications that they can take with them.