Medication reconciliation: more than just a best possible medication history.

T he Institute for Safe Medication Practices Canada (ISMP Canada) defines medication reconciliation as " a formal process in which healthcare providers work together with patients, families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care. " 1 It is based on " a systematic and comprehensive review of all the medications a patient is taking. .. to ensure that medications being added, changed or discontinued are carefully evaluated. It is a component of medication management and will inform and enable prescribers to make the most appropriate prescribing decisions for the patient. " 1 Medication reconciliation has been endorsed by patient safety organizations and implemented in many institutions around the world to ensure accurate communication on admission, on transfer, and at discharge. It was introduced into the Accreditation Canada program as a Required Organizational Practice in 2005, so for the past decade our health care institutions have been evaluated on their ability to comply with these standards, and compliance has improved throughout the country over this period. 2 Clearly, the medication reconciliation process has value, and few would debate that better communication about medications across the continuum of care can reduce medication-related adverse events and improve patient adherence with therapy. Improved communication about medications on transfer and at discharge may also decrease return visits to the emergency department and unplanned hospital readmissions, which together can significantly reduce the consumption of health care resources. Acquisition of a best possible medication history (BPMH) on admission is a critical step in medication reconciliation. Although often performed by a pharmacy team member, it can be accurately performed by any member of the health care team, including a student. There is clear evidence that pharmacists and other health care providers can obtain accurate BPMHs for patients on admission to hospital, a step that leads to the identification of medication discrepancies. 3 However, there remain challenges in completing the far more important task of utilizing the BPMH as part of medication management and pharmaceutical care. In other words, the BPMH is an important and necessary step, but it is the purposeful evaluation and resolution of the drug therapy problems (DTPs) identified that will do the most to improve patients' health outcomes. To date, resources for medication reconciliation have been focused on admission to health care facilities, with less attention paid to transfers within and discharges from these facilities. …