Saudi Journal for Health Sciences

: 2021  |  Volume : 10  |  Issue : 2  |  Page : 73--79

Impact of clinical pharmacist-led medication reconciliation on therapeutic process

Maram Mohamed Elamin1, Kannan Omer Ahmed1, Osman Khalafallah Saeed2, Mirghani Abd Elrahman Yousif1,  
1 Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Gezira, Sudan
2 Department of Gastroenterology, Medicine, Faculty of Medicine, University of Gezira, Gezira, Sudan

Correspondence Address:
Mirghani Abd Elrahman Yousif
Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Gezira


The role of clinical pharmacists in the medication reconciliation (MR) process has been limited in the literature. Medication discrepancies and drug-related problems are safety challenges for hospitalized patients and healthcare professionals. The MR process is a standard practical tool at different hospital settings to optimize the correct use of medicines. The aim of this review was to evaluate the role of clinical pharmacists in the implementation of MR process at different practice settings. A literature search of Google Scholar, PubMed, ScienceDirect, and ELSEVIER for “medication reconciliation” and “medication discrepancies” with “clinical pharmacist” from 2011 up to September 2020 was conducted. The search findings revealed that; clinical pharmacist is the most capable health care provider in implementation of MR process due to his vast experience in medication history taking and drug therapy management. Medication discrepancies that can result in serious discomfort or clinical impairment of patients can be prevented by a clinical pharmacist-led MR process. Studies confirmed that clinical pharmacist's interventions contribute substantially to the detection and resolution of medication discrepancies in hospitalized patients. Moreover, another estimated benefit of pharmacist-led MR was cost reduction for patients, families, and healthcare system. These findings highly recommend further inclusion of a clinical pharmacist in a team-based MR in different health settings.

How to cite this article:
Elamin MM, Ahmed KO, Saeed OK, Yousif MA. Impact of clinical pharmacist-led medication reconciliation on therapeutic process.Saudi J Health Sci 2021;10:73-79

How to cite this URL:
Elamin MM, Ahmed KO, Saeed OK, Yousif MA. Impact of clinical pharmacist-led medication reconciliation on therapeutic process. Saudi J Health Sci [serial online] 2021 [cited 2021 Nov 30 ];10:73-79
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Full Text


Medication reconciliation (MR) is a standard process in which healthcare professionals corporate with patients to guarantee comprehensive data of appropriately reported medications,[1] that is associated with drug-related problems and healthcare cost.[2] MR process during hospital transfer is one of the most difficult issues of inpatient care.[3] The process is mainly used to detect, identify, and resolve medication discrepancies.[4] Medication discrepancies occur as variations in reported drug regimens at different care sites and contribute virtually to adverse drug events in hospitalized patients.[5] Kraus et al. have encouraged further investigations or methods to increase the doctors' acceptance rate to adopt the pharmacist-led interventions to improve the MR process.[6] This review was primarily about whether the MR process led by clinical pharmacists has substantial impact on the therapeutic process. For the review, Google Scholar, PubMed, Elsevier, and ScienceDirect were searched for “medication reconciliation” and “medication discrepancies” with “clinical pharmacist” from 2011 up to September 2020. Studies in the English language describing clinical pharmacist-led MR process at different practice settings were retained.

 Significance of the Study

Medication discrepancies may lead to hospital readmissions, subtherapeutic doses, overdoses or toxicity, increased emergency department visits, and death.[6] The process of MR is fulfilled by healthcare professionals at different transitional care sites.[7] The American Society of Health System Pharmacists recommended that pharmacists should possess a key role in the MR process.[8] Thus, authors decided to review how the clinical pharmacist-led interventions significantly improve the MR process.

 Definition and Rationale For Implementing the Process in Hospital Settings

Different international patient safety institutions and organizations such as the Institution for Health Care Improvement, the World Health Organization, and Joint Commission International recognized MR as the fundamental process to ameliorate patient safety.[4]

According to the Institute for Safe Medication Practices Canada definition, MR is considered as “an official process in which healthcare providers working together with patients and families to ensure correct and comprehensive medication information is communicated properly across transitions of care.”[9]

Following admission to the hospital, it has been estimated that one of five hospitalized patients experienced a preventable medication-related injury.[10] The goal of the MR process is to resolve unlisted, intentional, and unintentional variances by reconciling all medications at all sites of care.[11]

 World Health Organization's Responsible For the Provision of Service

The process of MR incorporates an “expert healthcare provider” comparing medications ordered for a patient to the recent medications that are presently ordered and resolving any discrepancies.[8] However, a lack of agreement regarding the duties and responsibilities of each profession within the process is there.[12] Ward's attended clinical pharmacists have an expected effect on lowering the number of medication errors and upgrading clinical outcomes.[9] A study conducted at university teaching hospital in Ireland revealed that medical team-based clinical pharmacy services led to a considerable decrease in the occurrence of unintentional unresolved discrepancies when compared with conventional ones.[13] A qualified pharmacy technician can accomplish admission and discharge MR for patients with perfection and accuracy comparable to pharmacists working in a pharmacy.[14] Targeted internal medicine residents' training sessions result in an improvement in the accuracy of the process performed by resident doctors.[7] Kuwait study showed low awareness among doctors and pharmacists on hospital policies despite implementation of MR process being recognized as valuable.[15] A study conducted in academic medical center, North Carolina, USA, showed that the inpatient clinical pharmacist who daily attending medical rounds, reviewing and monitoring medications, and making recommendations to the medical staff considered to be the most expert health providers to perform MR.[16]

 Clinical Pharmacist-Led the Reconciliation Process

Inaccurate prescribing due to inappropriate medication history results in medication errors. Pharmacist-obtained medication history was more precise than those collected by other healthcare providers.[6] The more effort and time devoted by the pharmacist to obtain a comprehensive and accurate medication history than doctors decrease the prevalence of medication discrepancies obtained during a hospital transfer.[3] A prospective study carried out in two wards of internal medicine, French hospital, revealed that clinical pharmacists are well suited to upgrade medication safety during the hospital transfer and discharge because they are experts in drug therapy management and directly working with doctors, nurses, and patients.[17]

Clinical pharmacists can ideally influence doctors on their prescribing of medications because they have adequate knowledge in therapeutics and they are aware of their responsibilities in providing MR.[9] Thus, qualified clinical pharmacists conducting MR at admission and discharge assist to identify these discrepancies, improve the medication safety, prescribe modality, and consequently contribute in the reduction of medication errors.[11] Rhinehart et al., conducted multidisciplinary primary care network study in Central Ohio, reported that not only in the medical ward but also in different hospital departments, the pharmacist-led the postsurgical discharge program increased in MR process completion rates.[18]

 Importance of the Process in Identifying Medication Discrepancies and Adverse Drug Events at Different Transitions of Care

The National Transitions of Care Coalition defines transitions of care in hospitals as the movement of patients from one practice setting to another.[8] Further, the transition could be a movement between different healthcare practitioners as their clinical situation and care need change.[19]

The unintentional medication discrepancies are unexplained variations in reported medications among different points of care.[2] The undocumented intentional discrepancy is due to medication change made by another healthcare provider but not reported on the medication record, whereas an unintentional discrepancy refers to medication change made intentionally by the patient without the recognition of the medical care team.[1]

In the absence of the process of MR, hospitalized patients are at risk of harm from unintended medication discrepancies in the transition of care from home to hospital.[20] The discrepancy on admission, may be due to patients taking medications prior to admission which have not been added to the hospital medication list. The discrepancy on discharge may be the result of patients restarting medications upon back homes.[21] On admission, the reported interchanged medicines of the same therapeutic class for elders taking medications in any of commonly interchanged classes: proton pump inhibitors, histamine H2-receptor blockers, antihypertensive agents, lipid-lowering agents, and inhaled corticosteroids – raise the risk to potential drug-related problems during and posthospitalization.[22]

When comparing the hospital departments in terms of the prevalence of medication discrepancies, the internal medicine department is the most common one containing a high number of reported medication discrepancies.[23] It has been found that unintended medication discrepancies happened 38 times more frequent when there are no clinical pharmacist interventions.[17]

Process on hospital admission

Implementation of MR on admission exists in two models: The first is the proactive process, in which a recent drug history called “best possible medication history” is obtained before ordering medications. The second is the retroactive process, in this one, the drug history is obtained after the admission medication order.[17]

The existence of various sources of information to obtain a comprehensive medication history on admission is essential, so no single source of information provides all the pertinent details of the patient medication history. Detailed history using different sources of all medications' preadmission is required for a complete medication history, as shown in [Table 1].[20]{Table 1}

Thus, history taken to be completed by using sources of information mentioned above too also includes dietary supplements, vitamins, and herbal medicines.[24],[25]

A four-phased systematic approach was developed to upgrade the quality in terms of defining medication discrepancies; obtaining medicine information, a reflection of medicinal information, and the creation of the dataset; and measuring and recording medication inconsistencies. This multidisciplinary approach resulted in successfully recognized discrepancies among hospital and community pharmacy units.[26]

Importance of the process on admission

Medication discrepancies that can result in serious discomfort or clinical impairment of patients can be prevented by a clinical pharmacist-led MR process on admission.[27] Among identified total medication discrepancies detected at the time of hospital admission, 35% were classified as unintentional while the remaining were classified as intentional discrepancies.[28] The importance of a comprehensive medication history at hospital admission and putting in place MR program would improve patient safety and reduce medication-related problems during hospitalization.[19]

Process on hospital discharge

At the time of hospital discharge, the reconciliation of medicines and communication of information to the patients reduce the occurrence of discharge medication discrepancies.[29]

 Causes of Medication Discrepancies to Occur in Inpatient Records at the Time of Hospital Discharge

The presence of different documentation resources is considered as a primary cause of the medication discrepancies at hospital discharge. It is estimated that in a total number of discharged patients, 26% of the analyzed ones' charts contained at least one medication documentation discrepancy.[30]

Polypharmacy at discharge is correlated with an increase in undocumented medication discrepancies.[31]

Complex dosage forms or frequencies present at hospital discharge may cause discrepancies at home when patients are unable to clearly understand the instructions.[32]

Importance of the process at the discharge point

Among hospitalized patients in the medical ward, the number of ordered medications at discharge has been found to predict the period for first hospital readmission and the frequency of hospitalizations.[33] MR performed on patients with kidney disease with multiple drug therapy on nephrology department revealed that most drug-related problems could be prevented and resolved on discharge.[1]

 Other Tools Used to Reduce the Posthospital Discharge Medication Discrepancies

In addition to MR, tools have been used to reduce posthospitalization medication discrepancies at discharge, including medication education, discharge instructions and advices, follow-up phone calls, and reinforcing patients and families to bring all medications at follow-up visits.[2]

 Predictors and Risk Factors of Medication Discrepancies

The most significant risk factors and predictors that could increase the rate of medication discrepancies can be categorized as the following:

Medication-related factors

Increased number of medications, increases medication discrepancies.[6,34] Patients on more than 10 medications were more prone for medication discrepancies.[21] Discharged patients with multiple sources of information and medication records reported a high number of medication discrepancies compared with those of limited medication sources.[30]

Length of hospitalization

There is an association between length of hospital stay and increased proportion of undocumented discrepancies. When patients are hospitalized longer, more than one doctor would see the patient and different medication changes may occur.[31],[35]

Patient-related factors

The patients' nonadherence and functional, emotional, and behavioral factors also correlated with the increased proportion of medication discrepancies at discharge. Thus, proper patient education and counseling have been recommended to assist patients' understanding and adherence to their medication regimens.[32],[36] Regarding the patient's demographics, patients with more years of education have fewer errors of omission.[37]

Hospital-related factors

Admitting patients to hospital and patients transfer between different care settings had also been reported as a risk factor for unintended medication discrepancies, both among adults and children.[38] Patients admitted with an increased number of medications and in the existence of environment-related factors during hospitalization have been correlated with the prevalence of unexplained discrepancies.[39] A difficult environment in the emergency department to obtain medication history includes an increased number of patients, high patient–healthcare providers ratios, a large number of critical distractions, and shorter durations of stay compared to other wards. Many patients admitted to the emergency department are severely ill and may not be willing to provide comprehensive information about their medication therapy.[40] The type of medical specialty and the variability of hospital departments were found not to be significantly related to discrepancies.[41] Therefore, in the presence of such factors and lack of MR implementation during hospital stay, this consequently may result in increased medication discrepancies. Comprehensive and accurate medication lists at both admission and discharge may resolve many medication errors.[31]

Classification of medication discrepancies

Medication discrepancies are considered drug-related problems that may interact with the desired therapeutic outcome for the patient.[42] Types of medication discrepancies are scattered, they involved but not restricted to the following: an addition or omission of medication, alternative agent within the same therapeutic class, and alteration in dose, frequency, or route of administration.[43],[44] The omission of the baseline medication was the most frequent unintentional discrepancy.[4],[23],[24],[44],[45] However, it has been reported that at the first point of hospital transfer (admission), the most predominant discrepancies are inaccurate drug dose followed by an omission of medication.[41] Patients' charts from four inpatient units of a Canadian University Teaching Hospital were analyzed by clinical pharmacists and revealed that the majority of charts have a minimal documentation records.[46] Other types of discrepancies are “guidelines discrepancy,” which is documented as another class of discrepancies.[47]

 Categorization of Medication Discrepancies According to Patient Harm and Clinical Relevance

There are different categories and classifications of medication discrepancies according to the patient harm and clinical significance, as illustrated in [Table 2].[43]{Table 2}

In structured approach used, medication discrepancies identified for 80% of patients. Majority of discrepancies were evaluated to possibly harm the patient in a long-term perspective.

Another categorization of discrepancies classified according to the clinical seriousness and the need for intervention is shown in [Table 3].[48]{Table 3}

 The Financial Impact and Cost Effect of the Process on the Patient's Health

The acceptance of pharmacists' clinical recommendations by doctors and patients resulted in a cost reduction of drug therapy problems in the USA.[49] The pharmacist partnership in MR at different transitional care sites can result in cost avoidance for institutions.[50] Pharmacist involvement in the safe medicine's program has demonstrated success in preventing medication-related problems, resulting in upgrading outcomes while lowering costs for patients nationwide.[49]

 Barriers of Implementing the Medication Reconciliation Process

There are several barriers that could face the implementation of the process in real practice, e.g. improper medication documentation, untrained practitioners, and malcommunication skills.

Improvement Communication improvement among the medical team is important, that changes in patient medications made by specialists during hospital transfer should be documented to the other medical team members.[1] Miscommunication among healthcare providers is a major barrier to complete the reconciliation process. Providing particular communication guidance for the medical team during hospital transfer lowers medication discrepancies; this could be fulfilled by facilitating access to policies and medical history for providers.[51] Health information exchange may assist in achieving the goals of MR.[52]

 Implementation of the Process Using Novel Technologies

The urgent need for the process to prevent medication discrepancies in different hospital settings requires an easy and simple tool to perform it quickly and accurately. Hence, a new approach to electronic tools has been innovated and introduced into practice.

The MR application designed by a research team reflects the categorization and drug interactions and presents the medication information from different data sources, for example, patient, electronic medical report, and pharmacy. Further, it indicates discrepancies among sources and arranges the medication lists in an organized display for clinical decision-making.[53]

Participation of hospitalized patients in the MR process using tablets demonstrated a high willingness of patients to be engaged in the process and revealed that they were able to identify significant medication discrepancies and may upgrade medication safety during hospitalization.[5]

An automated electronic health record-linked e-mail reminder for the resident doctors is a new approach used to upgrade the records of MR on hospital admission.[54]

Although the clinicians balance the cognitive and behavioral needs posed by incoming information from different sources, electronic health systems face barriers to effective MR for ambulatory patients.[55] Further, compared to the clinicians, the electronic reconciliation process does not reduce adverse drug events or other medication-related problems.[56] The comparison between the manual and electronic MR process is illustrated in [Table 4].[57]{Table 4}


The high number of preventable clinically significant medication discrepancies in hospitalized patients at different transition sites of care indicates the real need for clinical pharmacist services. The clinical pharmacist's interventions contribute substantially to the detection and resolution of medication discrepancies in hospitalized patients. Moreover, another estimated benefit from the implementation of the MR process is cost reduction to patients, families, and the healthcare system.

Authors recommend for healthcare policymakers to expand the role of clinical pharmacists in planning and implementing the MR process at different practice settings, and training should be carried out. Further researches are needed to fill the gap in the literature to evaluate the numerous outcomes of implementing the MR process.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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