Br J Clin Pharmacol. 2016 Sep; 82(3): 645–658. Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has
been conducted and how medication discrepancies have been classified. We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a
classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors. Ninety‐five studies met the inclusion criteria. Approximately one‐third of included studies (n = 35, 36.8%) utilized a ‘gold’ standard medication list. The majority of studies (n = 57, 60%) used an
empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists. We suggest that clear and consistent
information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well‐designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice. Keywords: classification, medication discrepancy, medication error, medication
reconciliation, transition of care Medication reconciliation has been acknowledged by several international patient safety organizations such as The Joint Commission (TJC), Institute for Healthcare Improvement (IHI) and the World Health Organization (WHO) as important for achieving medication safety. These organizations have encouraged the implementation of the medication reconciliation
process to improve patient safety by identifying unintended medication discrepancies, especially at transitions of care. However, there are differences in the definition of medication reconciliation used by these organizations. For instance, the IHI defines medication reconciliation as: ‘the process of creating the most accurate list possible of all medications a patient is taking and comparing that list against the physician's admission, transfer, and/or discharge orders with the goal of
providing correct medications to the patient at all transition points within the hospital’ 1. However, TJC defines medication reconciliation as ‘the process of comparing a patient's medication orders to all of the medications that the patient has been taking’
2. The WHO defines the medication reconciliation process as ‘the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care’ 3. As a result, there is
variability in the guidance provided for conducting medication reconciliation and hence variability in medication reconciliation practices. While the concept of medication reconciliation seems relatively straightforward, implementing medication reconciliation has proved to be complex and challenging 4,
5. Nevertheless, medication reconciliation remains a critical patient safety activity that is supported by different international organizations to optimize patient medication safety at transitions of care. Adverse drug events and medication discrepancies continue to be a patient safety challenge for patient and healthcare professionals 6. Medication discrepancies are known to occur at transitions of care 7, 8 where patients often receive new medications or have changes made
to their existing medications. Although these changes may be intentional, unintended changes can also occur. This may be as a result of poor communication between healthcare professionals or between healthcare professionals and patients/carers 3,
9. Growing evidence indicates that medication discrepancies place patients at risk of medication errors and adverse drug events and have the potential to cause harm 7,
10, 11, 12. Approximately half of all hospital medication errors and 20% of adverse drug events occur as a result of
miscommunication at interfaces of care 13, 14. A comprehensive medication reconciliation service is a critical part of reducing medication discrepancies and adverse drug events
4. The term ‘medication reconciliation’ is relatively new and was coined in 2005 when National Patient Safety Goal (NPSG) 8 was introduced by The Joint Commission. Specifically, it sought to ‘accurately and completely reconcile medications across the continuum of care’
15. However, many hospitals found it difficult to implement medication reconciliation in a systematic way. Therefore, in 2009 TJC revised the NPSG and stopped considering medication reconciliation as a factor for accreditation decision 4. Despite
the inability of the health care institutes to ensure effective medication reconciliation, TJC reintroduced the medication reconciliation process in 2011 into (NPSG) 3, reflecting the significance of medication reconciliation to patient safety 9. Several medication reconciliation interventions have been evaluated to identify medication reconciliation best
practice. Mueller et al. indicated that the heterogeneity between medication reconciliation interventions and how they were evaluated produced significant barriers to identifying good practice 16. Lehnbom et al. demonstrated that the literature was highly diverse and there were inconsistencies between the majority of studies in terms of methods and
outcome measures, making it difficult to assess the influence of medication reconciliation 17. A review by Bayoumi et al. concluded that although there were similarities in interventions, populations and outcomes between studies, comparable results were not obtained due to the imprecise assessment of the impact of interventions
18. To evaluate the effectiveness and the impact of medication reconciliation interventions, we require a clear, consistent and sensitive measure. Although medication discrepancy is considered a sensitive product of continuity of care 19, Kostas
et al. argue that a standardized nomenclature for types of medication discrepancies and medication reconciliation best practice is needed 20. To our knowledge, medication reconciliation processes have not been investigated from this point of view. Hence, the main purposes of this systematic review were to: 1. analyse studies which aimed to describe the types of
medication discrepancies; 2. evaluate how medication discrepancies have been classified; 3. investigate the existence of taxonomies used to categorize medication discrepancies during a medication reconciliation process; 4. explore the extent to which these taxonomies are applicable in a clinical setting; and 5. describe factors influencing the standardization of medication reconciliation.
Articles describing types of medication discrepancies were identified by a systematic search following the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) as a guide 21. The search terms were established by the research team in collaboration with a medical librarian. We
searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstract (IPA) and Web of Science (WOS) for relevant articles up to 7 April 2016. No restriction on year of study was applied. The search strategy included two main terms ‘medication reconciliation’ and ‘medication discrepancy’ (the Supplement material includes the complete search strategy). We used the same search strategy in all databases taking into consideration the existence of the alternative terms in each database.
Medical subject headings (MESH)/EMTREE, keywords, titles and abstracts were searched in a Boolean search strategy. Initially, the term ‘classification system’ was used in the search strategy; however, we noticed that few articles were identified. Thus we did not include this term as it is not usually present as a keyword in published literature. We broadened the search strategy for the following reasons. First, the term ‘medication reconciliation’ was indexed as a MESH term in the MEDLINE
database in 2011. However, in the period between 2003 and 2010 it was classified under Medication Error/prevention and control. Second, the tree associated with the MEDLINE term ‘medication reconciliation’ showed that the term was classified under three more general terms: ‘medication errors’, ‘medication systems’ and ‘patient care management’. Third, the terms related to medication discrepancy were highly diverse in the literature. Therefore we searched alternative terms such as inconsistency
and drug‐related problems (DRPs). Studies were eligible for inclusion in this review if they: 1. involved medication reconciliation implicitly or explicitly – for the purpose of article identification, we defined medication reconciliation as a comparison between two or more medication lists; 2. mentioned the types of medication discrepancies in the study objectives or predefined outcomes; and
3. contained a classification system for medication discrepancies. We excluded non‐English language studies, systematic reviews and meta‐analyses, guidelines, conference abstracts, books and letters. We had no restriction on time, design and setting of the studies. The retrieved articles were transferred into Endnote to remove duplicates. Initial screening of titles was conducted independently by one author (EA) to remove irrelevant articles followed by assessment of abstracts and examination of
full‐text articles for inclusion. Any issues which arose through the selection and review processes were resolved by discussion between the research team (EA, RM and TC). In addition, 10% of included articles were verified by TC and RM. One researcher (EA) extracted the following data from the full text of included articles: study setting, transition point (timing of the intervention),
interventions, the person who conducted the intervention, data sources, classification terms, sources of classification terms, objectives, predefined outcomes if present, results, and whether the study distinguished between intentional and unintentional discrepancy. As we were looking for information relevant to the classification of medication discrepancies, we also recorded contributory factors, causes and resolution of medication discrepancies. Meta‐analysis was not applicable due to
heterogeneity in interventions, methods and reported outcomes. We believed that it was not necessary to assess the quality of included studies because we did not seek to identify the effects of interventions or clinical outcomes. Instead, our focus was on standardized methods for evaluating the medication reconciliation process. Initially, a total of 6318 potentially relevant articles were
obtained. The sample included 3335 duplicate records, which were removed. After screening titles and reviewing abstracts, 513 full texts were assessed for eligibility. Eventually 95 articles met all inclusion criteria and were included in our review. The remaining excluded studies were categorized based on reason for exclusion (Figure 1). More than half of our included studies were carried out in the US (48/95), while the remaining studies were conducted in 14 other countries. Most studies (65/95) were conducted in hospital settings, 28 in community settings and two studies in both the hospital and community
setting. The vast majority of studies were performed by a ‘pharmacy team’ (68/95, 71.6%). Other studies were conducted by nurses (9/95, 9.5%), physicians (2/95, 2.1%) or health care professional teams (e.g. pharmacy and physician) (8/95, 8.4%) 22. The profession of the persons who conducted the intervention was unclear in the remaining studies (8/95, 8.4%). Few
studies articulated that the health care professional received training before conducting the medication reconciliation intervention (16/95, 16.8%) (see Supplementary Table S1). Flow diagram showing sample selection process Transition of careThe most common transition point was admission to hospital (n = 36/95, 38.0%), followed by discharge from hospital, which involved studies conducted during discharge (12/95, 12.6%) and post‐discharge (12/95, 12.6%). Interestingly, the transition point was not identified in 18 studies (18.9%), with most of these studies conducted in the outpatient setting (e.g. dialysis facilities). Only two studies were conducted at the point of preadmission (e.g. preoperative clinic). The remaining studies (15/95, 15.8%) included numerous transition points. Classification of medication discrepanciesWe identified three pre‐defined/standardized taxonomies for classifying medication discrepancies resulting from medication reconciliation. They were the Medication Discrepancy Tool (MDT) (2004, USA) 23 , the APS‐Doc classification (2012, Germany) 24, and a taxonomy for unintended medication discrepancy (2012, Belgium) 25. The number of types of medication discrepancy in each tool was 19, 48, and 11 items, respectively. These tools were utilized in 11 studies (11.6%), three of which described the establishment of the tools. Most studies classified medication discrepancies empirically, based on the data collected (57/95, 60%). There were 22 studies (23.1%) that categorized the discrepancies based on other relevant studies published in the literature. For example, Agrawal et al. classified medication discrepancies based on Beers et al. 26 and Lau et al. 27 studies 28, 29. Five studies (5.3%) utilized a classification for (DRPs) such as the Hepler and Strand Classification 30, 34. The number of classification terms ranged from 2 to 50 terms. Additionally, a small number of studies (11/95, 11.6%) stated the reasons for discrepancies in their categories and seven studies described the interventions related to the medication discrepancies (Table 1). The most common type of discrepancy in our study sample was omission (n = 60/95, 63.2%). Table 1Availability of standard list, method of classification and the number of components in the classification of included studies (n = 95); the studies were stratified by transition points and date of publication
Medication discrepancyThere was diversity in the definition of medication discrepancy even when comparing studies conducted within the same setting and transition point. For instance, in two studies which evaluated medication reconciliation at the time of hospital admission, one defined medication discrepancy as an addition or withdrawal of a drug, or a change to the dose or dosage, whilst the other defined medication discrepancy as an unintended error in prescribing admission medications. More than half of the studies (49/95, 51.6%) utilized the terms intentional and unintentional in describing medication discrepancies. In addition to definition diversity, the term medication discrepancy was used interchangeably with other medication safety terms, such as prescribing errors and inappropriate medications; prescribing and transcribing errors; and DRPs (11/95, 11.6%). Regarding the process of gathering the medication lists, only 35 studies out of 95 (36.8%) stated the use of a comprehensive process in gathering the best possible medication history (BPMH) or gold standard list. The number of data sources used in these studies ranged from 1 to 9 (mean 3.8 sources). DiscussionThis is the first systematic review investigating the current status of medication discrepancy classification, describing its rational basis and indicating the importance of developing a well‐designed and validated taxonomy for medication discrepancies. The detection, prevention and resolution of medication discrepancies form essential steps in the process of medication reconciliation. Documenting and classifying medication discrepancies, therefore, is recommended for the implementation of medication reconciliation best practice and important for measuring the influence of medication reconciliation interventions on patient safety. However, our review confirmed that the classification methods for medication discrepancies were generally empirically based, indistinct and unstructured. Our review showed variability not only in classification of medication discrepancies but also in their definitions, causes and sources of information. We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well‐designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice. Several international organizations, including the WHO, TJC, the Australian Commission on Safety and Quality in Healthcare (ACSQHC), the National Institute for Clinical Excellence (NICE), the Institute for Safe Medication Practices (ISMP) and the IHI have campaigned for an increased focus on accurate information transfer at transition points in care 35. Accordingly, use of medication reconciliation has been promoted by these organizations, as a means to reduce medication error and prevent adverse drug events 15. Despite this worldwide attention, the proposed definitions and key steps in undertaking the medication reconciliation process vary between these organizations. IHI stated that ‘the term medication reconciliation has often been misinterpreted’, hence a clear definition for medication reconciliation is required. Furthermore, there has been a lack of agreement regarding the types of medication discrepancies. For instance, NPGS 2015 lists the following types of medication discrepancies in their latest goals: omissions, duplications, contraindications, unclear information, changes, interactions and the need to continue current medication 36; whereas ISMP classifies medication discrepancies as undocumented intentional discrepancies (not errors), unintentional discrepancies and intentional discrepancies 37. Ultimately, it is almost certain that the inconsistency between these prestigious international organizations has contributed to the heterogeneity in reporting between medication reconciliation studies and the corresponding difficulties in making comparisons between studies. The cornerstone for successful medication reconciliation is creating the best possible accurate medication list by using a systematic approach based on a patient/carer interview and a variety of other medication sources such as prescription bottles, discharge medication orders or pharmacy records. Numerous studies have suggested that no single source of medication use is fully accurate and reliable 38, 39, 40, 41, hence the need to utilize a variety of data sources. However most organizations acknowledge that the patient/carer must be included as a source of medication information in the medication reconciliation process, if a gold standard medication list or BPMH is to be obtained. The BPMH is defined as a history created using a systematic process of interviewing the patient/family; and a review of at least one other reliable source of information to obtain and verify all of a patient's medication use (prescribed and non‐prescribed) 37. Despite this, little attention has been given to the creation of a gold standard medication list. As an illustration, our findings revealed that more than two‐thirds of included studies did not utilize a gold standard medication list. However, Kostas et al. showed that approximately 51% of studies used a BPMH effectively 20. It is not surprising that the NPSG (2015) has explicitly stated the central role played by patients in achieving medication safety 36. In practice, reconciling a suboptimal medication history (as opposed to a best possible medication history) with the current medication order does nothing to improve patient safety, and instead could increase the risk of patient harm 42. In addition, we believe that such a comprehensive list is not only important for the medication reconciliation process but also for medication management review. In other words, carrying out medication review with an incomplete or inaccurate list could hide and or amplify medication‐related problems. Several process measures of ‘continuity of care’ were used in the literature, such as accuracy of transferred data, patient knowledge and adherence or quality of prescribing 19. Coleman and Berenson stated that process measures are particularly well suited to measuring transitional care 43, but these measures are highly diverse and ambiguous 19. Medication discrepancies represent a precise measure related to transitions of care. However, similar to medication reconciliation, agreement on the definition of medication discrepancies is lacking. As a consequence, authors have been compelled to create their own definitions, generally based on their research objectives and method. In addition, we identified five studies that did not utilize the term medication discrepancy when describing the medication reconciliation process 24, 30, 44, 45, 46, but instead used the terms ‘DRPs or medication‐related problems’, ‘inappropriate medication’, ‘prescribing error’ and ‘transcribing error’. It is noteworthy that the term ‘medication error’ has been used interchangeably with ‘medication discrepancy’ in several studies 40, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57. However, others have distinguished between the two terms based on the availability of a gold standard medication list. These studies suggest that in the absence of a gold standard medication list, the use of the term ‘medication error’ may not be appropriate. And using the term ‘medication discrepancy’ may provide a more practical approach to capture the events that occur at transitions of care 23, 58, as not all medication discrepancies are errors. The terms intentional and unintentional were often used in the literature to describe types of medication discrepancies. Our review revealed that more than half of the studies utilized these terms. However, using these terms is also open to interpretation as it is often difficult (or impossible) for an independent person to determine whether another person's actions were unintentional or not. In addition a review by Tam et al. describing the medication history errors at admission, stated that the discrepancies between physician‐acquired medication histories and comprehensive medication histories are not necessarily errors 59. But, we believe that no health professionals would intentionally make an error in taking a medication history. When the physician deliberately changes the therapy based on the clinical situation of the patient, using these terms seems reasonable, but remains inconsistent. For instance, several studies did not record an intentional undocumented discrepancy as an error 47, 60, 61, while others considered these discrepancies as errors 62, 63. In addition, some researchers recorded only the discrepancies that have been modified or changed by the prescriber 53, 64, 65. To understand the medication reconciliation process and identify the strategies for standardization, we need to clearly define and classify medication discrepancies as these are the sole quantitative measure related to the medication reconciliation process. Our review identified three published instruments designed to identify and categorize medication discrepancies. One of these tools, APS‐Doc, was developed to classify DRPs in a hospital setting. However, we considered this tool as it can be used in different medication management processes, including medication reconciliation. As a result, not all the items can be assigned to transitions of care. In our review, three studies utilized the APS‐Doc tool to classify the DRPs through the medication reconciliation process 44, 45, 46. The MDT and Claeys tool were developed to classify medication discrepancies across transitions of care. Both tools were designed for the post‐discharge context, and divided causes of discrepancy into patient and system levels. However, the definition of discrepancy varied between these tools. Claeys et al. defined medication discrepancies as medication‐related problems, while the MDT suggested that in the absence of a gold standard list, the term medication discrepancy may be more practical than the term medication error. While the items in Claeys tool may be assigned as unintentional medication discrepancies, the definition of medication discrepancy and the aim of the instrument were not clear 25. This instrument was not used in any other studies in our review. Regarding the MDT, we believe that this tool is helpful in understanding the sources and contributory factors related to medication discrepancies. However, it may be less valuable in classifying the types of medication discrepancies due to the restricted number of categories. The MDT tool has been used in three studies 58, 66, 67, and adapted in a further four studies by modifying subcategories to make them more applicable to their settings and design 69, 70, 71. Hence there is a striking gap in the literature concerning the classification of medication discrepancies based on a well‐structured taxonomy. Thus far, several reviews have been published in the literature in regard to medication reconciliation as an intervention to improve transition of care 16, 17, 18, 59, 72, 73. But their findings revealed that the effectiveness of medication reconciliation was uncertain and additional good quality studies are required. In our view, such findings are expected due to the lack of consistency in measuring, reporting and classifying of medication discrepancies, in addition to the lack of a standardized process for conducting medication reconciliation 20, 59. Our review differs from previous reviews in that we have not applied any limitation based on study setting, study design and or when the data were collected because we believe that these variables do not necessarily influence the types of medication discrepancies which occur. In addition, our focus was the systematic approach to classifying medication discrepancies identified from medication reconciliation practice. We believe this review makes important contributions to informing patient health and safety research and to our knowledge, we have described for the first time the approaches of medication discrepancy classification that have been used in the literature in addition to describing different elements for medication reconciliation best practice. Our review has several strengths especially in the search strategy, as we searched six different databases using the keywords in singular and truncated forms. Furthermore, we mapped the literature using MESH/EMTREE terms using a Boolean strategy. Thus the number of included studies was high compared to other related reviews. It is important to note that we found irregularity in indexing the term medication reconciliation over time; therefore, we broadened our search strategy to address this. In the future we recommend that databases, journals and other stakeholders adopt a more consistent approach to indexing and defining the keywords. This review is not without limitations: we included only English‐language studies and we did not include grey literature. In addition, we did not perform a quality assessment of the studies, as we believed that our objective would not be affected by the quality of design. ConclusionThe medication reconciliation process is important for facilitating medication and patient safety at transitions of care. However, a systematic approach to best practice has not been identified, nor is there a universally accepted taxonomy for classifying medication discrepancies. Hence more attention should be given to adopting a more standardized process for conducting and evaluating the practice of medication reconciliation. Building a well‐designed taxonomy for medication discrepancies might be the first step towards such standardization. Competing InterestsAll authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. We would like to thank the Faculty Liaison Librarian, Lorraine Evison, at The University of Sydney Medical Sciences Libraries for her support in building the search strategy for this review. ContributorsAll three authors were responsible for the conception and design of the study and also the analysis and interpretation of the data. EA wrote the first draft of the manuscript and, together with TC and RM, performed subsequent substantial revisions. All three authors were responsible for the critical revision of the manuscript for important intellectual content. EA takes responsibility for the integrity of the data and the accuracy of the data analysis. All of the authors were significantly involved in this work and provided final approval of the submitted manuscript. 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A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid
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