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Nurse-pharmacist collaboration on medication reconciliation prevents potential harm


  • Disclosure: The research was funded by the Interdisciplinary Nursing Quality Research Initiative, Robert Wood Johnson Foundation (RWJF). Leonard S. Feldman, Linda L. Costa, E. Robert Feroli Jr, Terry Nelson, Stephanie S. Poe, Kevin D. Frick, Leigh E. Efird, and Redonda G. Miller —Johns Hopkins received grant money for this research from RWJF. Linda L. Costa— the grant also provided support for travel to meetings for the study or other purposes. E. Robert Feroli Jr— Johns Hopkins pays for Dr Feroli's salary as the hospital's medication safety officer. Leigh E. Efird—the grant funding provided an honorarium for Dr Efird for her role as the pharmacist consultant.



Medication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs.


Nurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview. If a patient was not able to provide a written HML or recall medications, the nurses reviewed the electronic record along with other sources. The nurses then compared the HML to the patient's active inpatient medications and judged whether the discrepancies were intentional or potentially unintentional. This was repeated at discharge as well. If the prescriber changed the order when contacted about a potential unintentional discrepancy, it was categorized as unintentional and rated on a 1-3 potential harm scale.


The study included 563 patients. HML information gathering averaged 29 minutes. Two hundred twenty-five patients (40%; 95% confidence interval [CI], 36%-44%) had at least 1 unintended discrepancy on admission or discharge. One hundred sixty-two of the 225 patients had an unintended discrepancy ranked 2 or 3 on the harm scale. It cost $113.64 to find 1 potentially harmful discrepancy. Based on the 2008 cost of an ADE, preventing 1 discrepancy in every 290 patient encounters would offset the intervention costs. We potentially averted 81 ADEs for every 290 patients.


Potentially harmful medication discrepancies occurred frequently at both admission and discharge. A nurse-pharmacist collaboration allowed many discrepancies to be reconciled before causing harm. The collaboration was efficient and cost-effective, and the process potentially improves patient safety. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine