Performing Medication Reconciliation on Admission

Scenario

A new patient is admitted from home with several medication bottles and a handwritten list.
When you check the EMR, the pre-admission medication list is incomplete — only three medications are documented, but the patient reports taking “about ten.”

Question: How do you accurately complete the medication reconciliation and prevent potential errors during admission?

Best Practice Answer

1. Start with a Comprehensive Verification Process:
   Medication reconciliation is a critical safety step that ensures continuity of care. Begin by:

   • Asking the patient (or family/caregiver) to name all medications they take — prescribed, over-the-counter (OTC), herbal, and PRN.
   • Comparing the list against the patient’s physical bottles, labels, and previous records (from PCP, prior hospitalizations, or pharmacy).
   • Checking for duplicate therapies (e.g., two forms of the same drug) and verifying dosing frequency and routes.

2. Use Multiple Verification Sources:

   • Contact the patient’s outpatient or community pharmacy to verify dispensing history if medication bottles are incomplete or unclear.
   • If the patient is from a long-term care or rehab facility, request their most recent Medication Administration Record (MAR).
   • Collaborate with family members or caregivers when the patient has limited recall.

3. Clarify and Resolve Discrepancies Before Admission Orders:

   • Compare the compiled home list to the provider’s admission orders in the EMR.
   • Notify the admitting provider immediately of discrepancies, omissions, or contraindications (e.g., home lisinopril missing from order set).
   • Document your findings as “pending provider verification” if clarification is still needed — do not administer medications until confirmed.

4. Update the MAR (Medication Administration Record):

   • Once verified, update the EMR accurately with correct names, doses, routes, and frequencies.
   • Flag high-risk medications (anticoagulants, insulin, opioids) for pharmacy verification.
   • Ensure allergy and adverse reaction information is complete and up to date.

5. Communicate Clearly Across Disciplines:

   • Use SBAR format to communicate discrepancies or safety concerns to the provider and pharmacist.
   • Example:

     “Mr. Roberts takes warfarin 5 mg daily at home, but it’s not on the admission list. Confirm continuation or hold?”

   • This proactive approach prevents omissions and adverse drug events.

6. Educate and Involve the Patient:

   • Encourage patients to carry an updated medication list or use a digital app.
   • Reinforce understanding of why accurate reconciliation protects them from errors during transitions of care.

Real-World Application

Medication reconciliation is among the top causes of preventable hospital errors if done incorrectly.
Interviewers test this scenario to gauge:

• Your attention to detail
• Critical thinking in resolving conflicting information
• Accountability in maintaining safety through communication

This task is standard in med-surg, telemetry, and transitional care nursing, especially during admission, transfer, or discharge.

Tip: In interviews, emphasize ownership by saying —
“I verify the full medication list from multiple sources before giving any meds and notify the provider of discrepancies. Medication reconciliation starts with nursing accuracy, not just pharmacy.”
This demonstrates initiative, vigilance, and patient-safety leadership.