Medication Reconciliation at Hospital Admission and Discharge: How to Stop Information Getting Lost Between Departments

What is medication reconciliation, and how is it different from a medication review?

Medication reconciliation starts with a specific question: do we have correct and complete information about what the patient was using, and do the current orders match the intended treatment decisions? A medication review, by contrast, looks at whether the medicines suit the patient’s condition and weighs their benefits and risks. The two are linked, but collecting a correct list does not mean approving everything on it for continuation. ^[1]

An old prescription may differ from what the patient takes at home. A change in treatment may be intentional but not clearly documented. So not every discrepancy is classed as an error, and staff do not change treatment just because they found a difference. The difference is referred to the person with authority, and the explanation and decision are recorded. ^{[1, 3]}

The World Health Organization lists transitions of care among the priorities for medication safety in its 2024 policy brief. That more recent source supports the importance of the topic, alongside the specialist technical report published in 2019; being newer does not replace the detailed reference that fits the question. ^{[1, 2]}

How do you take a medication history you can rely on?

Start with a structured interview with the patient, or with a caregiver who can provide the information. Ask about prescribed medicines, over-the-counter products, supplements, herbal products and items the patient may not think of as “medicines”, such as some drops, inhalers and creams. Record the name, strength, dosage form, dose, route, frequency and last dose when the information is available. ^[4]

Avoid relying on the single question “Do you take any medicines?”. Helpful prompts include: What do you use every morning? Do you have an inhaler or drops? Has anything changed since your last visit? Then verify the information against a suitable additional source, such as the packs, the dispensing record or the previous care provider, respecting access rights and privacy. ^{[4, 5]}

Write down the source of each piece of information and when it was collected, and show what is still unresolved. “Awaiting verification” means the work is still open; it is clearer than an empty field that could be misread as “no medicine”. Missing data is never filled in by guesswork.

What do you do when the list differs from the orders?

Compare each item on the list with the orders relevant to that transition. A discrepancy may be an omission, an addition, or a change in dose or frequency. The aim is to find out whether the difference is intentional and documented, and to go back to the authorised prescriber when the intent is unclear or a correction is needed. ^[3]

A practical suggestion for the team: give each discrepancy a short follow-up record covering the problem, who it was referred to, when, the decision, and where it was updated in the file. This stops a note from becoming a dangling comment that nobody owns. The record is not used to make automated treatment decisions.

It also helps to separate two states in the documentation screen: “not yet reviewed” and “reviewed and approved”. A staff name or a saved tick does not necessarily show whether the content review is complete. Adopting these states needs team agreement and must fit the information system and facility policy; it is not just a matter of adding new buttons.

Who collects the information and who resolves discrepancies?

The facility assigns the work according to staff competence, authority and service coverage hours. This covers who takes the history, who verifies it, who compares the lists, who has authority to prescribe or amend, and who makes sure the information arrives at the transition. The MATCH toolkit supports designing one shared, interdisciplinary process rather than separate lists that are hard to reconcile. ^[3]

Improvement starts with a team that brings together medicine, pharmacy, nursing, quality and information systems as the project needs. Map the current way of working before changing it: Where is the information written? When does it move? Where is the interview repeated without adding real verification? This picture helps you choose a realistic pilot scope and identify gaps and responsibilities. ^[8]

For example, management might choose one ward to pilot the model and appoint a coordinator to follow up obstacles. This is an organisational suggestion for piloting, not a general requirement or a mandatory staffing model. The decision depends on service size, resources and local clinical policy.

What does a breakdown look like in a hypothetical case?

Imagine a patient transferred from one department to another, while an earlier order stayed in the record and it was no longer clear whether it should continue. A team member noticed a difference between the transfer summary and the current list, but the note stayed in a separate message. The message did not say who would ask for clarification or where the answer would be documented.

In the suggested organisational fix, the discrepancy is recorded in the shared place, referred to the authorised prescriber, the reply is documented and the relevant list is updated. The receiving team then checks that the decision is visible in the transfer documents. The problem here is not a shortage of forms, but the lack of a clear route to close the issue.

This is a hypothetical teaching case prepared by Nevada, not a published incident at a hospital or a research finding. We do not assume that continuing or stopping is the right decision; the aim is to show how the question reaches the responsible person and how the answer is tracked until documentation is complete.

What information must arrive at discharge?

A transition of care needs an updated, understandable list that explains the changes and the reasons for them to the receiving provider and to the patient or caregiver, according to the approved procedure. The MATCH toolkit stresses giving the patient updated medication information at discharge and linking it to what they were using before admission. ^{[3, 5]}

In the discharge summary, set aside space for what changed, who is responsible for follow-up, and how to get in touch with questions. Medicine names and instructions are completed by the treating team only. Use language that suits the reader, and leave room for questions rather than just handing over a long sheet of paper.

One training idea is for trainees to review two hypothetical versions of a discharge summary: one shows the decision and its reason, the other lists names only. The team discusses what information the receiver needs to understand the change and what is still unresolved. This exercise assesses the quality of communication without using real patient files.

How do you adapt this to a healthcare facility in the Gulf?

Before adopting the procedure, the facility links it to its own medication policies and to the local requirements that apply to it. This article does not offer a single compliance checklist for the Gulf states, and it does not attribute clauses to CBAHI or any regulator without referring to the text in force. Use it as a framework for internal discussion, then carry out a separate check against the competent authority’s requirements.

Suggested adaptation questions include: Which languages do our patients need? How do we obtain information from another facility in an authorised way? Who covers verification outside working hours? Where does the receiving team see the latest approved list? The answers should be settled in the work procedure and the training, and staff should know the escalation route when a reliable source cannot be reached.

How do you know training improved the work?

Do not settle for measuring attendance or the number of completed forms. The MATCH toolkit distinguishes between auditing adherence to the process and auditing the quality of what was done, and suggests tracking results before, during and after the change. Review the completeness of information and the resolution of discrepancies, not just whether a document exists in the file. ^[6]

The facility can define one indicator for completeness of verification and another for closing discrepancies under its policy, specifying the sample, numerator, denominator and exclusions. These are suggested indicators that need local definition; we do not set a general success rate or time limit for them without a reference or a baseline. Discuss the causes of shortfalls with staff to see whether they relate to training, role allocation or the system. ^[6]

Base training on shared cases for doctors, nurses and pharmacists, with practice in interviewing, documentation and discussing discrepancies. Interdisciplinary training helps each role see how it depends on the others. You can end the session with a practical task: complete the record of the hypothetical case, identify what needs referral, and state when you consider the documentation complete. ^[5]