Medication Reconciliation: How to Update Medication Lists Across Care Settings

Every time a patient moves from one care setting to another-whether it’s from home to the hospital, from the ER to a ward, or from hospital to a nursing home-there’s a real risk that their medication list gets lost, mixed up, or forgotten. This isn’t just a paperwork issue. It’s a safety issue. In fact, medication reconciliation is one of the most effective ways to stop preventable harm before it happens.

What Medication Reconciliation Actually Means

Medication reconciliation isn’t just making a list. It’s a structured, step-by-step process to make sure every medication a patient is taking-prescription, over-the-counter, vitamins, herbal supplements, even traditional remedies-is accurately recorded and matched across every point of care. The goal? To catch mistakes before they hurt someone.

This process was formalized in 2005 by the Institute for Healthcare Improvement and later adopted by The Joint Commission as a National Patient Safety Goal in 2006. Why? Because research showed that 50-70% of patients experience a medication error during a care transition. And 20-30% of those errors could lead to serious harm.

Think about it: A 72-year-old woman with high blood pressure, diabetes, and arthritis comes into the ER after a fall. She’s on seven medications at home. But she can’t remember all the names. Her daughter thinks she’s on three. The hospital’s system shows five. The pharmacy record shows six. Without reconciliation, she might get a duplicate dose of her blood thinner, miss her insulin, or get a new drug that interacts badly with her current ones.

The Five Steps That Save Lives

There’s a clear, proven process for doing this right. It’s not complicated, but it’s not optional. Here’s what it looks like:

1. Get the Best Possible Medication History (BPMH) - This isn’t just asking the patient. It’s calling their pharmacy, checking their primary care records, talking to family, and reviewing old discharge summaries. Studies show that relying only on what the patient says leads to errors in 42% of cases.
2. Create the new medication list - Based on the current clinical needs, what meds should they be on now? This list comes from the doctor’s orders, specialist notes, or discharge instructions.
3. Compare the two lists - Side by side. Look for missing drugs, wrong doses, duplicate therapies, or interactions. Clinical decision tools flag about 15-25% of lists as having potential issues.
4. Resolve the differences - Why was a drug stopped? Was it because it caused side effects? Was it redundant? Was it an error? Every change needs a documented reason.
5. Communicate the final list - To the patient, their family, the next provider, the pharmacy. If the list doesn’t reach the next person, the whole process fails.

Who Does This? And Why Pharmacists Are Key

You might think nurses or doctors handle this. But the gold standard? Pharmacists. The American Society of Health-System Pharmacists says it plainly: pharmacists are the medication experts. They’re trained to spot interactions, catch dosing errors, and understand why a drug was added or removed.

At hospitals where pharmacists lead reconciliation, medication errors drop by 47% compared to nurse-only teams. One study at Mayo Clinic showed their pharmacist-led program prevented over 1,200 adverse drug events each year and cut 30-day readmissions by 18%.

But here’s the catch: In many places, pharmacists are stretched thin. Nurses and techs are asked to do reconciliation on top of everything else. And when time is tight, corners get cut. A 2022 survey found that 41% of nurses admit they sometimes skip full reconciliation because they’re overwhelmed.

The Tech That Helps-And the Tech That Doesn’t

Electronic health records (EHRs) like Epic and Cerner have reconciliation tools built in. Some platforms, like MedsReview, claim 37% higher accuracy in community settings. Surescripts connects 90% of U.S. pharmacies, giving providers access to prescription history.

But technology alone doesn’t fix the problem. A 2021 study in JAMA Internal Medicine found that 31% of reconciliation errors still happen-even with digital tools-because the systems aren’t used well. Doctors click through checkboxes without reading the discrepancies. Pharmacists are buried in alerts that don’t prioritize the real risks.

And data gaps? They’re everywhere. Only 43% of discharge summaries include a complete, updated medication list. That means when a patient goes home, their pharmacist or primary care doctor often has to guess what changed.

Real Problems Real People Face

Patients aren’t always the problem-but they’re often the biggest obstacle. Many older adults can’t name their meds. They don’t know why they take them. One pharmacist on Pharmacy Times said 40-50% of elderly patients can’t accurately describe their own prescriptions.

That’s why tools like patient medication diaries help. Patients who write down their meds-name, dose, time, reason-see a 27% improvement in accuracy during reconciliation. But only 33% of hospitals even ask patients to bring these in.

And the confusion doesn’t stop at discharge. A 2020 study found that 61% of patients left the hospital confused about their new meds. Nearly 3 out of 10 changed their doses or stopped taking something on their own within a week. That’s not noncompliance. That’s a system failure.

What’s Changing in 2025

Regulations are tightening. In 2023, CMS increased the weight of Medication Reconciliation Post-Discharge (MRP) from 5% to 8% of Medicare Advantage star ratings. Hospitals that don’t meet standards face lower payments.

The ONC’s USCDI Version 4, rolled out in January 2023, now includes standardized medication reconciliation data elements. That means systems should be able to talk to each other better. The 21st Century Cures Act also pushes for interoperability, which should help.

And now, reconciliation must include herbal remedies and traditional medicines. The National Center for Complementary and Integrative Health found that over half of patients use these-yet most EHRs still don’t have fields to capture them.

AI is starting to help. Google’s DeepMind Health tested an AI tool that predicted medication discrepancies with 89% accuracy. But it still needed human review. Because no algorithm can ask a patient, “Did you stop that pill because it made you dizzy?”

What Works-And What Doesn’t

Successful programs share common traits:

• Dedicated staff-reconciliation technicians or pharmacists assigned just to this task.
• Standardized workflows-no one guessing what to do next.
• Time built into the schedule-15-20 minutes per admission, 10-15 per discharge.
• Training-8-12 hours of specialized education, with certification through CCPIT.
• Follow-up-contacting patients within 7 days of discharge to confirm understanding.

At Johns Hopkins, they cut medication discrepancies by 72% in 18 months using this approach.

What doesn’t work? Treating reconciliation as a checkbox. Filling out a form because the system requires it, without actually reading the list. Letting the EHR auto-populate without verification. Assuming the patient knows their own meds.

Why This Matters More Than Ever

Medication errors don’t just cost money-they cost lives. Adverse drug events cause 6.5% of all hospital admissions. For medical inpatients, that number jumps to 19%. In 2023, CMS penalties for avoidable readmissions averaged 0.64% of Medicare payments. That’s real money.

But beyond the numbers, it’s about trust. Patients need to know their care team has their full story. They need to walk out of the hospital knowing exactly what to take, when, and why.

Reconciliation isn’t a task. It’s a promise. A promise that no one’s medication will slip through the cracks. That no one will get a dangerous combo because someone forgot to ask about the turmeric supplement. That no one will be sent home with a new drug they don’t understand.

It’s not glamorous. It’s not flashy. But when done right, it’s the quiet hero of patient safety.