Medication Reconciliation: It’s Not Just a List

By Karen Gunning and Katie Traylor



Across America, clinics are humming with the sounds of automated blood pressure cuffs, the beep of thermometers, and the clink of the scales. A commonly heard phrase in these clinics during the patient rooming process is: “What medications are you taking?” These five words comprise one of the most important parts of the patient history-gathering that goes into each primary care visit, but this phrase is often not sufficient to get to the real answer.

As much as 92.5% of the time in primary care clinics, medication reconciliation – or more precisely, the process of establishing the correct medication list – is incomplete or flat out wrong. Wrong drugs, wrong doses, wrong dosage forms, and our favorite, the drugs that are discontinued but never taken off the medication list in patients’ medical records. While electronic prescribing is a fantastic tool to get prescriptions to a pharmacy efficiently, one important drawback looms in all pharmacists’ minds and comes as a surprise to many providers – when a medication is discontinued from an electronic medication list in clinic, no message or notification is sent to the patient’s community pharmacy to discontinue the medication and, therefore, the patient can still fill and take the eleven remaining refills that you thought had been discontinued.

With nearly one in three adults in the United States taking five or more medications daily, and some patients taking up to thirty or forty maintenance medications, it is absolutely overwhelming to consider the amount of work needed to get this seemingly simple task done, and done right. The dangers of continuing discontinued medications can be equally overwhelming, though these are not always obvious to the patient or their health care team members.

Take for example, a patient who has been switched from one blood pressure medication, lisinopril, to a different blood pressure medication, amlodipine, due to an adverse side effect with the lisinopril, such as elevated serum potassium. The patient’s primary care provider sends a prescription for the new amlodipine to the patient’s pharmacy and removes the old lisinopril from their clinical medication record, feeling good about recognizing and addressing this issue. However, the patient didn’t fully understand that the doctor was stopping their lisinopril because it was causing high potassium levels, and they have six months of refills remaining at their pharmacy. The pharmacy fills the new prescription for amlodipine and continues to fill lisinopril on their automatic refill system until it runs out of refills six months later. Meanwhile, the patient is experiencing low blood pressure, dizziness, nausea, and palpitations due to continuing this discontinued lisinopril prescription. It’s easy to imagine how a situation like this can quickly lead to patient harm without the health care team or the patient even realizing how this error slipped through the cracks.

Like so many other areas of primary care, medication reconciliation must be a team effort. Repetitive training and practice can provide a framework for our primary care medical assistants and nurses to assist with this important task, but providers and patients should be involved as well. Even insurance companies, and their pharmacy benefit managers, can play an important role in this process – every provider has likely received a letter or fax from an insurance company with notification of a duplicate therapy being filled by a patient, or some other potential medication error. While these notifications are not always relevant or concerning, they can be instrumental in communicating some piece of the medication reconciliation puzzle from a patient’s multiple community pharmacies to their primary health care team.

Currently, in our electronic medical record, medication lists are available for patients to view in the patient web portal. While some patients are taking the time to review and update their medication records through this portal, many are not even aware that they have the ability to do so. Furthermore, even when a patient suggests changes online, these changes must be reviewed and accepted into their chart by someone in the clinic. For patients who do not have access to this online portal, medication lists are printed on their after-visit summaries following each clinic appointment, but we must encourage patients to thoroughly review these updated lists frequently and compare them with their home medication stock. If medications are changed or discontinued, patients should be given information or advice on how to properly discard of these old medications to avoid stock-piling drugs they aren’t even supposed to be taking, much less ten years after their expiration dates.

The next time you hear a patient in your primary care clinic state, “I just take whatever the pharmacy gives me…it should all be on that list in your computer…,” we hope you will pause and take a few extra minutes to call the patient’s pharmacy, ask the patient to bring all their medications in to the next visit, or call in a team member who can review the patient’s medications more thoroughly. Every effort to reconcile a patient’s medications and establish a correct medication list can prevent multiple medication errors and potentially save a patient from serious harm, and every team member in primary care has the opportunity to offer this protection to our patients.



gunning Karen Gunning, PharmD, BCPS, BCACP, FCCP, Professor and Interim Chair of Pharmacotherapy, Adjunct Professor of Family & Preventive Medicine  


Katie Traylor, PharmD, BCACP, BC-ADM, Assistant Professor of Pharmacotherapy and Adjunct Assistant Professor of Family & Preventive Medicine

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