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MED PRO
Medication Reconciliation:
A Vital Step in Patient Care
By MedPro Group Patient Safety & Risk Solutions
In the practice of medicine, careful evaluation of patients’ medical • Document all medication orders, including refills, in the pa-
history and current health status is an essential element of quality tient’s medical record. Ensure this information is located in a
patient care and an important initial step for safe medication pre- prominent place. Documentation should include ample infor-
scribing. Gathering and maintaining detailed and accurate informa- mation, such as drug name, dose, administration route, fre-
tion “is the first priority in medication safety, as it guides physicians quency, and purpose.
to choose the appropriate medication, dose, route, and frequency.”1
• When transferring patient care to another provider outside of
One of the most important steps in patient evaluation is medica- your medical practice, send a thorough and detailed list of the
tion reconciliation. Given that an estimated 4 out of 5 Americans patient’s medications to the new provider.
take at least one medication and almost a third take five or more
medications,2 it ngerousrovider and taking any number of over-the- Prescribing medication is a complex process, particularly as the
counter (OTC) products, supplements, or herbal remedies..riptions number of prescription drugs on the market continues to grow and
from more this reasonable to assume that patients are receiving pre- the prevalence of polypharmacy increases. By implementing a sound
scriptions from more than one provider and taking any number of and thorough medication reconciliation process, physicians can es-
over-the-counter (OTC) drugs, supplements, or herbal remedies. tablish the basis for medication safety and quality patient care in
their medical practices.
Comprehensively reviewing all medications and products that pa-
tients use — as opposed to only the medications prescribed at a sin- References:
gle practice — and keeping up-to-date medical records can help 1 Jenkins, R. H., & Vaida, A. J. (2007). Simple strategies to avoid
physicians make informed treatment decisions and reduce the risk
of dangerous or undesirable medication interactions. medication errors. American Academy of Family Physicians. Re-
trieved from http://www.aafp.org/fpm/2007/0200/p41.html
The following risk management strategies
offer guidance for managing and improving 2 The Centers for Disease Control and Prevention. Medication
the medication reconciliation process. safety basics. Retrieved from http://www.cdc.gov/Medication-
Safety/basics.html
• At each office visit, review all medications the patient is taking,
including prescription drugs, OTC medications, herbal prod- This article was produced by the Patient Safety & Risk Solu-
ucts, dietary supplements, vitamins, and alternative therapies. tions Team at MedPro Group, a national leader in healthcare mal-
practice insurance coverage and risk solutions. For additional
• To assist with reconciliation, ask the patient to bring his or her information, please visit the MedPro Group website at
medications, or a written list of medications, to the appoint- http://www.medpro.com/.
ment.
The information provided in this article should not be con-
• Document all information related to drug, material, or food al- strued as medical or legal advice. Because the facts applicable to
lergies in a prominent and consistent location in the patient’s your situation may vary, or the regulations applicable in your ju-
medical record. List the name of the allergen, the date the al- risdiction may be different, please contact your attorney or other
lergy was identified, and the patient’s reaction. professional advisors if you have any questions related to your legal
or medical obligations or rights, state or federal statutes, contract
• Consider offering the patient medication management tools, interpretation, or legal questions.
such as wallet cards or forms to help assist with the reconcilia-
tion process. Various organizations offer these types of re- © 2016 MedProGroup.® All rights reserved.
sources, including the Agency for Healthcare Research and
Quality, the Institute for Safe Medication Practices (ISMP), and
the American Medical Association.
visit us at www.bcms.org 43
