How And When Errors In Inpatient Medication Reconciliation Occur

Ruzanna Harutyunyan's picture

The Joint Commission made inpatient medication reconciliation a National Patient Safety Goal in 2005, focusing nationwide attention on the issue of errors in inpatient medication records as they move in and out of the hospital. According to a new study from researchers at Brigham and Women's Hospital (BWH) and Massachusetts General Hospital, inpatients experience an average of nearly one and a half potentially harmful errors in their medication record during a hospital stay. Unique from previous research, the study goes on to uncover the frequency of different kinds of errors, at what point during the process they most often occur, and factors that place a patient at risk for having these errors occur. These findings appear in the September 2008 issue of the Journal of General Internal Medicine.

Inpatient medication reconciliation is the process of identifying the most accurate list of all medications a patient is taking and using the list to provide correct medications for the patient. Until now, the attention has been on meeting this requirement without understanding where efforts should be focused. This study exposes the specific times during an inpatient visit when medication reconciliation errors most often occur. Seventy two percent of potentially harmful discrepancies are due to errors in taking patients’ medication history, while only twenty six percent occur while reconciling medication history with discharge orders. Also, the majority of discrepancies are due to the omission of medications, which account for more errors than incorrect reports of dosage, frequency, substitutions, and the addition of medications combined.


“This information can help guide hospitals in determining where to focus their efforts for addressing this problem,” said Jeffrey Schnipper, MD, MPH senior author and Hospitalist at BWH, who also notes that some hospitals are now assigning pharmacists to take inpatients’ medication histories at admission.

Though the majority of errors occur at the time of admission, the potential to cause harm generally occurs at discharge. At discharge patients can be sent home without necessary medications, with additional unnecessary medications, or on the wrong doses. “Medication discrepancies at discharge are especially dangerous because patients are no longer being monitored consistently and may not recognize signs of medication problems on their own,” Schnipper said.

Researchers also uncovered several predictors that can help professionals identify inpatients that are at higher risk for discrepancies in their medication records. Indicators of a higher risk inpatient include those with six or more medication changes during hospitalization; minimal understanding of preadmission medications; a caregiver providing medication information; thirteen or more outpatient visits during the previous year; an admission history taken by an intern; or four or more high-risk medications prescribed prior to admission.

“With patients today on more medications than in days past, the stakes are higher than ever before,” Schnipper says of reconciling medication. “Knowing when and where to look for discrepancies will help hospitals prevent errors that could cause harm to patients.”