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Medication risks

Safe care and medications

Medication reconciliation

Female pharmacist smilingMedication reconciliation is a process in which accurate and complete medication information for the patient is communicated at all transitions of care — from healthcare facility admission to discharge. Since the process involves multiple healthcare professionals (e.g. physician, nurse, pharmacist), effective team communication is essential.

Stages of the medication reconciliation process

The medication reconciliation process should be completed at each stage of the patient's hospitalization:
  • Admission: Evaluate each of the patient's home medications and determine if they should be continued, modified, or discontinued.
  • In-hospital transfer: Evaluate whether the patient's present hospital medications should be continued and whether home medications should be resumed, modified, or discontinued. Note: Transfer refers to a change in service, level of care (including post-operative), or hospital unit.
  • Discharge: To avoid duplicating, omitting, or prescribing unnecessary medications, cross-reference the patient's home medication list with the most recent medication administration record to compare and evaluate all:
    • pre-hospital medications
    • medications started or modified in hospital
    • planned post-discharge medications

Case: Resident unaware of patient's anticoagulated status at admission
Close up of forehead with cut


An elderly long-term care facility patient on warfarin falls and sustains a large head laceration, but does not lose consciousness. Facility staff provide a list of the patient's current medications to the paramedic who, in turn, gives the list to the emergency department (ED) triage nurse.

Although the nurse notes in the ED medical record all of the patient's medications, including warfarin, she does not verbally communicate this information to other ED personnel. The ED resident does not review the patient's list of home medications, so he is unaware of the patient's anticoagulated status.

After examining the patient and suturing the laceration, the ED resident discharges the patient back to the long-term care facility.


No imaging is ordered because the ED resident believes there is no clinical indication for it.

The patient subsequently dies of an undiagnosed subdural hemorrhage.

Think about it

What do you think contributed to this adverse event (accident in Québec)?

Lessons learned

  • A better patient outcome might have resulted if the triage nurse had notified the ED resident and other ED personnel of the patient's anticoagulation medication.
  • If the ED resident had reviewed the patient's list of home medications in the ED record, he would have noted the patient was on warfarin and might have ordered further diagnostic investigations (e.g. International Normalized Ratio [INR] level, head CT scan).

Medication reconciliation safeguards

Experts have suggested in the CMPA case files that the following medication reconciliation safeguards be considered:
  • Obtain an accurate and complete list of the patient's current home medications upon admission.
  • When possible, confirm the medications and dosages with the patient or family or substitute decision-maker.
  • Refer to the patient's home medications list when writing orders at admission, transfer, and discharge.
  • When discharging a patient, compare and evaluate all pre-hospital medications, medications started or modified in hospital, and planned post-discharge medications. Clarify any discrepancies.