Errors in the prescribing and administration of medication are frequent, costly and harmful (Bates 2007). More than 40% of medication errors take place as a result of inadequate reconciliation of medications at transitions of care (Hughes 2008). Transitional care provides for the continuity of care as patients move between different stages and settings of care (Coleman 2004). The prevalence of medication discrepancies arising at transitions of care have been reported in many different settings (hospital, community and long-term care facilities) and stages of care (admission, transfer and discharge); in particular transitioning from an inpatient to an outpatient setting is associated with an increase in medication errors relative to other stages of care (Boockvar 2006; Coleman 2004; Moore 2003; Tam 2005). Prevalence of adverse events post-hospitalisation as high as 19% have been reported with the majority of these related to adverse drug events, which may be the result of medication error. (Forster 2003). Medication discrepancies as patients transition to home from hospital have also been linked with increased re-hospitalisation rates (Coleman 2005).
"Medication reconciliation is a conscientious, patient centred, inter-professional process that supports optimal medicines management" (Greenwald 2010). It is an attempt to prevent medication errors at patient transition points. It is intended to be the process of creating the most accurate list of medications at all transition points, with the goal of providing the correct medications to the patient (Karapinar-Carkit 2011). Different patient groups and locations have been subject to study. A variety of intervention types have been investigated for the reconciliation of medicines including information technology (Kramer 2007; Schnipper 2009), pharmacist-led (Gillespie 2009), and more complex multi-faceted interventions (Koehler 2009). The benefits of medication reconciliation interventions are often assessed by comparing medication regimens across transitions and reporting discrepancy reduction as the primary outcome. A previous systematic review reported that although unintended medication discrepancies are common, clinically significant discrepancies may affect only a few patients (Kwan 2013). Challenges arise in identifying those discrepancies that are considered clinically significant and which may give rise to patient harm.... The recognised difficulty in undertaking appropriate comparisons and selection of relevant outcome measures is seen by the fact that while reported interventions have a positive effect on reducing the prevalence of medication discrepancies, the evidence for the presumed subsequent reduction in patient harm or healthcare utilisation is equivocal (Mueller 2012).
Therefore despite reconciliation being recognised as a key aspect of patient safety there remains a lack of consensus and evidence as to the most effective methods of implementing reconciliation and calls have been made to strengthen the evidence base prior to widespread adoption (Greenwald 2010).
Description of the condition
Transitional care describes the care provided to patients to ensure the coordination and continuity of healthcare as they transfer between different settings and/or different stages of care within the same settings (Coleman 2003b). Examples of care settings include locations such as hospitals, subacute and long term nursing facilities, patients' homes, primary care offices, and assisted living facilities (Coleman 2003b). Stages of care within these care settings may include admission, transfer and discharge. Transitions of care are associated with medication errors and patient harm. Greater coordination and attention to care transitions have been brought about by regulatory changes and financial penalties for "hospital-acquired conditions" (Jenq 2012). Furthermore, improved continuity of prescribed medication via medication reconciliation for patients at transitions of care is recommended by national standard setting bodies and internationally led initiatives e.g. World Health Organization (WHO)'s High 5's project (IHI 2011; NICE 2007; WHO 2006). However, the most effective method of conducting reconciliation remains unclear.
Description of the intervention
Medication reconciliation consists of the following three steps (IHI 2011).
Verification: A current medication list is developed using one or more sources of information (e.g. general practitioner medical records, patient's own supply, pharmacy records).
Clarification: Medication and dosages are checked for appropriateness. Here appropriateness means ensuring that there are no unintentional changes, rather than a medication review leading to optimal medication appropriateness).
Reconciliation: Newly prescribed medications are compared to old and any changes made are documented.
How the intervention might work
Failure to reconcile medications can result in medication error and subsequent adverse drug events (IHI 2011). Interventions to improve medication reconciliation may work by improving the communication between all those involved in the medication use process (dispensing, administration, monitoring across settings and stages of care), including the patient. Additionally these interventions may well help in reducing transcribing errors, improved monitoring of prescriptions, information technology systems and reorganisation of care delivery.
Why it is important to do this review
Medication reconciliation is incorporated into the National Patient Safety Goals of the Joint Commission under the umbrella of improving the safety of using medications (The Joint Commission 2013). The National Institute for Health and Care Excellence (NICE) in collaboration with the National Patient Safety Agency in the UK encouraged the standardisation of reconciliation processes within healthcare organisations (NICE 2007). The Canadian Patient Safety Institute and the Institute for Safe Medication Practices (Canada) have advocated for medication reconciliation and the WHO launched the High 5's project in 2006, with an emphasis on patient safety with the standard operating procedure - 'assuring medication accuracy at transitions in care' focused on reducing medication discrepancies (WHO 2006). Despite the high level of interest in implementing medication reconciliation the most effective process of conducting reconciliation remains unclear. A consensus statement from key stakeholders has called for further efforts to identify the best practices surrounding medicine reconciliation and their wider dissemination (Greenwald 2010).
The seminal Institute of Medicine report titled "To Err is Human: Building a Safer Health System" highlighted medication error as being widely prevalent, costly and contributing to preventable causes of patient injury (IOM 1999).The findings of this proposed review are relevant at both a national and international level. Regulatory bodies, healthcare institutions, patient safety advocates, healthcare practitioners and the wider public would be receptive audiences for the findings from a systematic review of the most effective method of medicines reconciliation.