Medication Reconciliation

Joint Commission NPSG 03.06.01 medication reconciliation at admission, transfer, and discharge. Compares the current med list against home meds + ordered meds to catch errors.

Steps

• Confirm the reconciliation trigger
  The admitting, transferring, or discharging clinician verifies that medication reconciliation is required for the current transition of care. Record the transition type in the EHR before proceeding.
• Collect the best possible home medication history
  The nurse or pharmacist obtains the patient’s home medication list from the patient, caregiver, outpatient pharmacy, prior records, or other approved sources. Include prescription medications, over-the-counter products, vitamins, supplements, and as-needed medications when available.
• Compare home medications against current orders
  The pharmacist or authorized clinician compares the home medication history against the current ordered medications. Review each medication for omission, duplication, dose difference, route difference, frequency difference, formulation difference, and therapeutic duplication.
• Resolve each discrepancy with the responsible prescriber
  The clinician contacts the responsible prescriber for each unexplained discrepancy and confirms whether the medication should be continued, modified, held, or discontinued. Document the rationale for each decision in the EHR.
• Update the active medication list
  The clinician updates the active medication list to match the final reconciled orders. Remove discontinued medications, add newly ordered medications, and correct dose, route, and frequency details as needed.
• Communicate the reconciled list at discharge or transfer
  The discharging or transferring clinician provides the reconciled medication list to the receiving care team and the patient or caregiver, including start, stop, and changed medications. Confirm understanding using the organization’s teach-back process when required.
• Document completion and escalate unresolved issues
  The clinician documents completion of medication reconciliation in the EHR. If any medication history cannot be verified, or if a high-risk discrepancy remains unresolved, escalate to the pharmacist, attending provider, or unit supervisor according to facility policy.