August 2021
Medication Discrepancy and the Importance of Medication Reconciliation
Schyuler Barbour-Johnson, MSN, CRNP, ANP-BC

There have been several patients with medication discrepancies after hospitalization or acute care setting. In one case, a patient’s antiplatelet medication was labeled as take one daily, twice a day. The patient was taking the medication one tab in the morning and two tabs in the evening. After a review of the discharge instructions and a conversation with the pharmacy, it was determined that the medication should be one tab, twice a day. In another case, a patient’s diuretic was not restarted after an acute care stay. The home health nurse noticed the edema in her legs but did not have a diuretic on her medication list. The hospital discharge instructions included the diuretic. The patient thought the medication was discontinued since it was not delivered by the pharmacy. After a discussion with the physician, it was determined that the diuretic was mistakenly not prescribed. It was immediately restarted. As you can see, in both cases there was miscommunication from different settings that resulted in medication discrepancies. Fortunately, there were no serious injuries or harm in these cases.

As health care providers work towards completing the daily tasks to ensure quality of care and patient safety, the list of tasks seems to be increasing by the day. One of the goals for quality of care is to provide accurate medications administration. When you think of patient safety with regard to medication, you think of the right medication, dosage, frequency, and patient adherence. Transitions of care, especially when moving from an acute care setting to the community or long-term care setting is an especially sensitive time since patients are at risk for medication discrepancy. Healthcare settings have implemented processes to prevent medications flaws and we continue to need a check and balance system. Medication discrepancy can contribute to adverse drug reactions, which may require rehospitalizations, Emergency Room (ER) visits, or provider visits. Medication reconciliation after hospitalization is key to improving safety, reducing medication discrepancy, and reducing medical legal liability.

In a study by Neumiller, Settler et al, 89% of the patients had at least one medication discrepancy upon discharge from the acute care setting. Of the 89% medication discrepancies, 41% were potential adverse drug events. The cost of adverse drug events (ADEs) was greater than $117 billion in 2000. Most of the ADEs were related to a lack of communication or documentation from the health care team or misunderstanding from patients/caregivers. The top five medications involved in potential adverse drug events were antihypertensives, opioids, anticoagulants, antidiabetic agents (oral and injection), and inhaled medication for chronic obstructive pulmonary disease or asthma. It was revealed that 73.3% of ADEs were managed telephonically, 12.5% required an office visit, 11.5% were unlikely to require any contact by healthcare providers, 2.1% required an ER visit, and 0.6% required hospitalizations.

In another study by Graabaek, Terkildsen, et al, 87% of the patients experienced at least one undocumented medication discrepancy from hospital discharge. This study revealed that 38% of the medications were changed without documentation in patient records, mostly over-the-counter (OTC) medications. The lack of accurate medications list obtained on admission to hospital and polypharmacy were related to undocumented medication discrepancies.

Health care systems have a different format for discharge instructions, and some are more detailed than others. Some discharge instructions include a section labeled stop and start medication and contain a list for each section. Other discharge instructions just list the medications which lead to someone (patient, caregiver, or provider) having to compare the preadmission medications to the discharge medications in the instruction list. This can expose the older adults to a confusing environment with discharge medication which can increase the risk of medication discrepancy. A detailed explanation of discharge instructions is vital prior to discharge from the health care setting. Be mindful of non-prescribed medications and remember to ask about OTC or herbal medications which may not have been communicated. Patients may feel these medications are not of importance. If there are any questions about a medication from discharge documents, ask questions by contacting the previous health care setting or clarify with providers or specialists.

A comprehensive medication reconciliation after a hospitalization or acute care setting is a key factor in eliminating medication discrepancies. Whether we work in a community or inpatient setting, a complete medication list upon admission and a medication reconciliation after discharge from an acute care setting will decrease the risk of medication discrepancy. Although a detailed medication reconciliation can be time-consuming; the end outcome will decrease risk of hospitalization or additional provider visits and improve quality of care. To quote Maya Angelou, “All great achievements require time.”

Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates, and members.
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AMDA membership is not required to access, however you will need to create an account (which is free) if you don’t already have one.
Balancing Act: Optimizing Use of Antihyperglycemics in PALTC 
Date: Thursday, August 19
Time: 4:30 PM – 5:15 PM ET
Fee: FREE

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