Medication Reconciliation at Discharge

Best Practices

Created on November 15, 2017

“Insanity is doing things the way we’ve always done them and expecting different results.”
Albert Einstein

Medication reconciliation (MedRec) at discharge is a priority indicator for the Quality Improvement Plans (QIPs). This indicator measures the total number of discharged patients for whom a best possible medication discharge plan was created as a proportion of the total number of patients discharged.

Below are best practices for managing and improving this indicator. They are graded according to Type of Evidence. Evidence-informed best practices are based on high-quality evidence; they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice, you can refer to the one of the following resources:

Or browse the interactive table below for some key change ideas on how to improve medication reconciliation at discharge.

  1. Allison, G.M., Weigel B., Holcroft C. (2015).
    Does electronic medication reconciliation at hospital discharge decrease prescription medication errors?.
    International Journal of Health Care Quality Assurance. 28(6):564-573.

  2. American Medical Association.
    The physician's role in medication reconciliation: issues, strategies and safety principles.
    Making Strides in Medication Safety Program. 2007:1-37.
    Retrieved from: http://bcpsqc.ca/documents/2012/09/AMA-The-physician%E2%80%99s-role-in-Medication-Reconciliation.pdf

  3. Bassi J, Lau F, Bardal S. (2010).
    Use of information technology in medication reconciliation: a scoping review.
    Ann Pharmacother.; 44(5):885-97.

  4. Bell CM, Brener SS, Gunraj N, Huo C, Bierman AS, Scales DC, Bajcar J, Zwarenstein M, Urbach DR. (2011).
    Association of ICU or Hospital Admission with Unintentional Discontinuation of Medications for Chronic Diseases.
    JAMA; 306(8): 840-847.

  5. Boockvar KS, Blum S, Kugler A, Livote E, Mergenhagen KA, Nebeker JR, Signor D, Sung S, Yeh J. (2011).
    Effect of Admission Medication Reconciliation on Adverse Drug Events from Admission Medication Changes.
    Arch Intern Med; 171(9):860- 861.

  6. Boockvar KS, Santos S, KushnirukA, Johnson C, Nebeker JR. (2011).
    Medication Reconciliation: Barriers and Facilitators from the Perspectives of Resident Physicians and Pharmacists.
    J Hosp Med; 6(6):329-372011;6(6):329-337.

  7. Caroff D.A., Bittermann T., Leonard C.E., Gibson G.A., Myers J.S.(2015).
    A Medical Resident-Pharmacist Collaboration Improves the Rate of Medication Reconciliation Verification at Discharge.
    Joint Commission Journal on Quality & Patient Safety. 41(10):457-461.

  8. Dhaliwall, S., Thompson J. (2013).
    Telepharmacy helps Ontario community hospital provide 24/7 service.
    Canadian Healthcare Technology; November/December Issue.
    Retrieved from: http://www.northwesttelepharmacy.ca/pdf/Canadian%20Healthcare%20Technology%20Reprint%202013.pdf

  9. Ehnbom E.C., Raban M.Z., Walter S.R., Richardson K., Westbrook J.I. (2011).
    Do electronic discharge summaries contain more complete medication information?
    A retrospective analysis of paper versus electronic discharge summaries.
    Health Information Management Journal. 43(3):4-12.

  10. Forster AJ. Clark HD. Menard A, Dupuis N, Chernish R. et. aI. (2004).
    Adverse events among medical patients after discharge from hospital.
    Can Med Assoc Journal; 170(3):345-349

  11. Giménez Manzorro Á, Zoni AC, Rodríguez Rieiro C, Durán-García E, Trovato López AN, Pérez Sanz C, Bodas Gutiérrez P, Jiménez Muñoz AB. (2011).
    Developing a programme for medication reconciliation at the time of admission into hospital.
    Int J Clin Pharmacy; 33(4):603-9.

  12. Gilbert A.V., Patel B., Morrow M., Williams D., Roberts M.S., Gilbert A.L. (2012).
    Providing community-based health practitioners with timely and accurate discharge medicines information.
    BMC Health Services Research. 12:453.

  13. Gleason KM, McDaniel MR, Feinglass J, Baker DW, Lindquist L, Liss D, Noskin GA. (2010).
    Results of the Medications at Transition and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission.
    J Gen Intern Med; 25(5):441-447.

  14. Hayes C, Yousefi V, Wallington T, Ginzburg A. (2010).
    Case study of physician leaders in quality and patient safety, and the development of a physician leadership network.
    Healthcare Quarterly; 13(Sp): 68-73.

  15. Haynes K.T., Oberne A., Cawthon C., Kripalani S. (2012).
    Pharmacists' recommendations to improve care transitions.
    Annals of Pharmacotherapy. 46(9):1152-1159.

  16. Heyworth L. et al. (2014).
    Engaging patients in medication reconciliation via a patient portal following hospital discharge.
    Journal of American Medical Informatics Association; 21 (e1): e157 - 162.

  17. Holland D.M. (2015).
    Interdisciplinary collaboration in the provision of a pharmacist-led discharge medication reconciliation service at an Irish teaching hospital.
    International Journal of Clinical Pharmacy. 37(2):310 -319

  18. Keeys C., Kalejaiye B., Skinner M., Eimen M., Neufer J., Sidbury G., Buster N., Vincent J.(2014).
    Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model.
    American Journal of Health-System Pharmacy. 71(24):2159-2166.

  19. Kwan JL, Lo L, Sampson M, Shojania KG.
    Medication Reconciliation During Transitions of Care as a Patient Safety Strategy: A Systematic Review.
    Annals of Internal Medicine. 2013;158(5 Pt 2):397-403.

  20. Lee K.P., Nishimura K., Ngu B., Tieu L., Auerbach A.D. (2014).
    Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists.
    Annals of Pharmacotherapy. 48(2):168-177.

  21. Lee J., Leblanc K., Fernandes O., Huh J.H., Wong G.G., Hamandi B., Lazar N.M., Morra D., Bajcar J.M., Harrison J. (2010).
    Medication reconciliation during internal hospital transfer and impact of computerized order entry.
    Ann Pharmcother; 44(12):1887-1895.

  22. Mekonnen A.A., McLachlan A.J., Brien J.A.(2016).
    Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.
    Journal of Clinical Pharmacy & Therapeutics. 41(2):128-144.

  23. Moore P, Armitage G, Wright J, Dobrzanski S, Ansari N, Hammond J, Scally A. (2011).
    Medicines reconciliation using a shared electronic health care record.
    J Patient Safety; 7(3):148-154.

  24. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. (2006).
    Hospital-Based Medication Reconciliation Practices: A Systematic Review.
    Archives of Intern Medicine; Jul 23;172(14):1057-69.

  25. Poon EG, Blumenfield B, Hamann C, Turchin A, Graydon-Baker E, McCarthy PC, Poikonen J, Mar P, Schnipper JL, Hallisey RK, Smith S, McCormack C, Paterno M, Coley CM, Karson A, Chueh HC, Van Putten C, Millar SG, Clapp M, Bhan I, Meyer G, Gandhi TK, Broverman CA. (2006).
    Design and implementation of an application and associated services to support multidisciplinary medication reconciliation efforts at an integrated healthcare delivery network.
    J Am Med Assoc; 13(6):581-592.

  26. Rafferty A., Denslow S., Michalets L.E. (2016).
    Pharmacist-Provided Medication Management in Interdisciplinary Transitions in a Community Hospital (PMIT).
    Annals of Pharmacotherapy. 50(8):649-55.

  27. Sanchez S.H., Sethi S.S., Santos S.L., Boockvar K. (2014).
    Implementing medication reconciliation from the planner's perspective: a qualitative study.
    BMC Health Services Research. 14:290.

  28. Vira T, Colquhoun M, Etchells EE. (2006).
    Reconcilable differences: correcting medication errors at hospital admission and discharge, Quality and Safety in Healthcare: 1–6.

  29. Walsh KE, Ettinger WH, Klugman RA. (2009).
    Physician quality officer: a new model for engaging physicians in quality improvement.
    American Journal of Medication Quality; June 1;24(4): 295-301.


Created on November 15, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.


Medication Reconciliation at Discharge

Topic Patient Safety and Never Events
Quality Dimension Safety
Type of Indicator Outcome
Measure Rate per total number of discharged patients.
Percentage (%)
Data Source In house data collection.
Data Collection Instrument These data should be accessed from within your own organization.
How to Calculate

The percentage is calculated as: (Numerator/Denominator) x 100

Numerator: # of discharged patients for whom a best possible medication discharge plan was created.

Denominator: # of patients discharged from the hospital.

See the Indicator Library for specifics on calculating this indicator.

Target Higher is better
Range 0 – 100%
HQO Reporting Tool Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.


Created on November 15, 2017


Medication errors at discharge can compromise otherwise excellent care received in hospital and in the home. In a recent study, 43% of patients experienced medication errors at discharge, which put most at risk of moderate harm (Riordan et al., 2016). Harmful medication errors can lead to hospital readmissions, which is an important consideration for hospitals in Ontario where the 30-day readmission rate is 11.6%.

Call to Action

Medication reconciliation (Med Rec) is a formal, systematic process in which health care professionals partner with patients to ensure accurate and complete medication information during transitions of care (Bernier et al. 2009). The result of discharge medication reconciliation should be clear and comprehensive information for the patient and other care providers. According to Safer Healthcare Now, and the Institute for Safe Medication Practices Canada, discharge medication reconciliation clarifies the medications the patient should be taking post discharge by reviewing:

  • Medications the patient was taking prior to admission (Best Possible Medication History - BPMH)
  • Most current medication administration record (MAR) or medication profile;
  • New medications planned to start upon discharge.

MedRec, when properly performed as part of a comprehensive, patient-centred discharge process, has been shown to have a positive impact on patient outcomes and satisfaction (Lambrinos, 2015).

  1. Bernier P, Boiteau P, Cass M, Couves L, Esmail R, Harries B. Safer Healthcare Now!
    Campaign April 2009 How-to Guide: Rapid Response Teams.
    Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Rapid%20Response%20Teams/RRT%20Getting%20Started%20Kit.pdf

  2. Institute for Safe Medication Practices (ISMP) Canada.
    Definition of Best Possible Medication History (BPMH).
    Available from: https://www.ismp-canada.org/medrec/

  3. Lambrinos A. (2015).
    Medication Reconciliation at Discharge: A Rapid Review.
    Health Quality Ontario.
    Retrieved from: http://www.hqontario.ca/Portals/0/Documents/evidence/rapid-reviews/qbp-chf-medrec-20141211-en.pdf

  4. Riordan CO, Delaney T, Grimes T. (2016).
    Exploring discharge prescribing errors and their propagation post-discharge: an observational study.
    Int J Clin Pharm; 38(5):1172-1181.