Medication reconciliation
- Safe practice
Reconciliation means comparing the medications the patient took at home with those ordered on admission, on transfer and at discharge.
What it is
Medication reconciliation is a formal process to make the patient's medication list complete and correct at every transition of care: admission, transfers between units or institutions, and discharge. The best possible medication history is taken (from the patient or family and at least one other source), compared with the current orders, and any difference without a documented reason is clarified with the prescriber. WHO includes it in its «Medication Without Harm» challenge, because discrepancies affect almost every patient who moves between levels of care, and Colombia's Ministry of Health recommends it in its patient-safety packages.
What it requires
- Time and a quiet place to interview the patient or family.
- More than one source of information.
- Communication with the prescriber and the pharmacist.
- The reconciled list recorded in the clinical record.
Components
- Collect: the full list of prior medications (name, dose, route, frequency, last dose taken).
- Compare: with the admission, transfer or discharge orders.
- Resolve: clarify omissions, duplications, different doses or interactions.
- Communicate: record the final list and hand it to the next team and the patient.
How it is applied (and why)
- Ask the patient or family about each medication, including over-the-counter and herbal ones — what is not asked is not recorded.
- Ask for prescriptions, packaging or the previous record — a second source fills the gaps.
- Note name, dose, route, frequency and time of the last dose — prevents double or missed doses.
- Compare the list with the current orders — look for omissions, duplications and changes.
- Tell the prescriber about differences with no documented reason — only the prescriber can say if they are intended.
- Record the reconciled list and hand it on at transfer or discharge, explaining it to the patient — the information follows the patient.
In nursing practice
- The nurse is often the one who takes the medication history on admission.
- At discharge, teach the patient which drugs to stop, which to continue and which are new.
- Older adults on many medications are at higher risk of discrepancies.
Common mistakes
- Using only one source (the patient's memory).
- Forgetting over-the-counter drugs, drops, inhalers or patches.
- Copying the previous list without comparing it with the new orders.
- Discharging without explaining the changes.
Test yourself
Think of the answer, then tap the question to see it.
When is medication reconciliation done?
At every transition of care: on admission, on transfer and at discharge.
What is the best possible medication history?
A complete list taken from an interview with the patient or family and checked against at least one other source.
What is done with a difference between the home list and the orders that has no documented reason?
It is reported to the prescriber to clarify, and the decision is recorded.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Medication safety in transitions of care (World Health Organization, 2019); Mejorar la seguridad en la utilización de medicamentos. Paquetes instruccionales, versión 2.0 (Ministerio de Salud y Protección Social de Colombia, 2015).
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Representative model, for educational purposes only.