Medication Reconciliation and Review

Medication Reconciliation

Medication reconciliation is the formal process of obtaining and verifying a complete and accurate list of all medicines a patient is currently taking and comparing this list with the patient's medication orders to identify and resolve discrepancies. The Joint Commission International and the World Health Organization recognise medication reconciliation as a key patient safety strategy — unintentional medication discrepancies are a leading cause of preventable harm during care transitions (hospital admission, transfer, and discharge).

The Reconciliation Process

Medication reconciliation follows a structured process often summarised as "collect, compare, communicate."

Collect: Obtain the best possible medication history (BPMH) from all available sources: patient interview, medication lists, dispensing history from the pharmacy software, GP records, previous discharge summaries, and if available, the shared care record. Include all prescribed medicines, OTC products, vitamins, herbal supplements, and PRN medicines. Document drug name, dose, route, frequency, and indication for each item.

Compare: Compare the BPMH with current medication orders. Identify three categories of discrepancy: (1) unintentional omissions — a medicine the patient was taking has not been charted; (2) unintentional additions — a medicine has been added without clinical reason; (3) unintentional alterations — an incorrect dose, frequency, or route.

Communicate: Discrepancies should be resolved with the prescriber and documented clearly. On discharge, a complete discharge medication list must be provided to the patient, GP, and community pharmacy.

Transitions of Care

The highest-risk times for medication errors are at care transitions. Hospital admission is associated with omission of regular medicines; discharge is associated with medication reconciliation errors, restarting previously stopped medicines, and failure to communicate dose changes. Studies show that pharmacist-led medication reconciliation at these transitions reduces medication errors by up to 80%.

In NZ, the Medicines Reconciliation standard is incorporated into the Health Quality and Safety Commission's medication safety programme and the national patient safety goals.

Medication Review — Types and Process

Medication review is a structured, critical evaluation of a patient's medicines aimed at optimising drug therapy and minimising drug-related problems. Types of review range from simple repeat prescription review (without patient contact) to a full clinical medication review conducted by a pharmacist with access to the patient's complete medical record.

Indication review: Is each medicine still indicated? Common targets for deprescribing include PPIs prescribed without a documented indication, statins in patients with limited life expectancy, and bisphosphonates after 5 years without fracture risk reassessment.

Efficacy review: Is the medicine achieving therapeutic goals? Blood pressure at target? HbA1c controlled? Asthma symptom-free days acceptable?

Safety review: Are drug-drug interactions or drug-disease interactions present? Is the dose adjusted for renal or hepatic impairment? Are potentially inappropriate medicines (Beers Criteria, STOPP/START criteria) present in older adults?

Adherence review: Is the patient taking the medicine as prescribed? Are there practical barriers (blister packs, dosing complexity)?

Deprescribing

Deprescribing is the planned and supervised process of dose reduction or cessation of a medicine that is no longer benefiting the patient. The goal is to reduce medication burden, polypharmacy, and adverse drug reactions. The pharmacist's role includes identifying candidates for deprescribing using validated tools (e.g., the NZ Deprescribing Guidelines), collaborating with the prescriber, and monitoring for withdrawal effects.