How to do a medication reconciliation

Guest post by: Stephanie Kujawski, PharmD, BCPS

For this post I'm excited to welcome Stephanie Kujawski, PharmD, BCPS! Steph graduated from UNC-Chapel Hill in 2011 and completed a PGY1 residency in 2012. After practicing inpatient internal medicine for almost 8 years in 3 states, she is excited to transition to an ambulatory care neurology clinic in the coming weeks. She spends her free time trying to convince her wily quarter horse to stand still and hiking the Appalachians as much as possible.

This article was originally published on, a site dedicated to helping medical professionals simplify clinical topics, survive residency, and become better practitioners.

[PC]: I thought a lot of community pharmacists might be interested in reading just what it takes on the inpatient side to get a medication reconciliation done, and I also added some tips throughout on how you can help out your local hospitals.

Medication Reconciliation – How Can It Possibly Be THIS Hard?!

When Brandon asked me if I’d write a post about medication reconciliation (aka med rec), I actually laughed out loud.

Not because I regularly laugh at Brandon (rather, I laugh with Brandon), but because, much like Prince John’s quiet machinations to take Richard’s throne, med rec has literally been insidiously creeping in to take over my work life for the past few months.

So it was a timely request, to say the least!

How can this topic usurp my work life, you ask. Well, I suppose we should start back with some definitions, and then I’ll try to illustrate some of the areas where something that seems oh-so-simple becomes oh-so-complicated. Hence, the aforementioned coup.

What is a Med Rec?

So if I was to describe med rec to my non-healthcare system mom, I’d tell her that it’s a term used to encompass all the decisions made about a person’s medications when they change level or location of care.

This includes...

  • When a person is admitted to the hospital from home or a facility

  • When that patient is transferred from the ICU to the general medicine floor (and maybe even back to the ICU again)

  • When the patient is discharged from the hospital to home or a facility

  • And even after the patient is home and following up with his Primary Care Provider (PCP)

In each of these settings, a person requires various medications or doses that may or may not be their norm.

For example, the septic patient in the ICU may need stress dose intravenous hydrocortisone, but by the time they’ve improved enough to transfer to the floor, maybe they don’t need such high doses anymore.

So each time the patient moves, a provider should review the medication list and decide what is still necessary versus what can be stopped or adjusted. This review and decision process is medication reconciliation. Seems pretty straight-forward and simple, right?


So many areas where things can go awry.

In the spirit of trying to keep this as organized as possible, I’ll just say that, in the remainder of this post, we’re going to discuss the whos, whats, hows, and whens of med rec.

And we’re going to follow my favorite patient again. Why can’t Han just stay out of trouble?

A Case Study in Medication Reconciliation

Han was flying around the universe with Chewbacca in the Millenium Falcon when all of a sudden he developed severe chest pain and shortness of breath.

Chewy rapidly contacted Rebel 911, who brought him back to solid ground in their ambulance ship, and Han was rushed to the nearest medical center.

Han is now lying in a bed in the emergency room, when Nurse Leia enters to greet him (she’s multitalented, k?).

So at this point, the medical team needs to know more about Han. This includes knowing if he takes any medications at home so they can decide what to order for him as an inpatient. This info can also help the team know whether any of his home medications could be contributing to his current clinical picture.

But what if 4 other patients came into the ER at the same time? Who is the highest priority, and how is that decided?

This is a question for which we don’t really have a well-defined answer. Prioritization of patients both in the ER and on the hospital floors is difficult.

Many institutions utilize some sort of scheme, which might include:

  • Length of time from admission

  • Acuity of the patient

  • Number of medications on a prior medication list

  • Risk of readmission

But these aren’t exactly validated schemes or parameters, and further work is needed to determine how to prioritize taking a patient's medication history.

Also, who should be the one to ask Han about his home meds? Should it be Nurse Leia, Dr. Spock, or pharmacy personnel? If pharmacy, should it be a pharmacist, a pharmacy technician, or a pharmacy student? Does it matter?

If all 3 disciplines ask him about his home medications, will everyone end up with the exact same list?

Unfortunately, odds are that each person will walk away with a different list, especially if Han has an extensive list of medications.