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Pharmacy Tech Topics™
VOLUME 26 NO. 3 | JULY 2021
A Comprehensive Review of Medication
Reconciliation Practices for Pharmacy Technicians
AUTHORS: Sabra Douthit, PharmD
Medication Reconciliation Coordinator, Geisinger Medical Center; Danville, PA
Daniel S. Longyhore, PharmD, EdD, BCACP
System Director of Knowledge Management, Geisinger Medical Center; Danville, PA
PEER REVIEWERS: Erin Carson, PharmD, BCPS
Clinical pharmacist, University of Illinois at Chicago College of Pharmacy, Rockford, IL
Kristine Hayes, CPhT
Pharmacy Technician Specialist, University of Illinois Medical Center, Chicago, IL
EDITOR: Patricia M. Wegner, BS Pharm, PharmD, FASHP
DESIGN EDITOR: Melissa Dyrdahl, BA
Pharmacy Tech Topics™ (USPS No. 014-766) is published quarterly for $50 per year by the Illinois Council of Health-
System Pharmacists, 4055 N. Perryville Road, Loves Park, IL 61111-8653. Phone 815-227-9292. Periodicals Postage
Paid at Rockford, IL and additional mailing offices.
POSTMASTER: Send address changes to:
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COPYRIGHT ©2021 by the Illinois Council of Health-System Pharmacists unless otherwise noted. All rights
reserved. Pharmacy Tech Topics™ is a trademark of the Illinois Council of Health-System Pharmacists. This
module is accredited for 2.5 contact hours of continuing pharmacy education and is recognized by the Pharmacy
Technician Certification Board (PTCB). Cover image property of ©2021 Adobe Stock.
LEARNING OBJECTIVES
Upon completion of this module, the subscriber will be able to:
1. Define medication reconciliation and describe when it should occur.
2. Describe the differences between the terms medication reconciliation and medication history.
3. Describe how to implement a medication reconciliation process.
4. Identify resources used to obtain a best possible medication history.
5. Explain how a pharmacy technician could participate in the medication reconciliation process.
ACCREDITATION
Pharmacy Tech Topics™ modules are accredited for Continuing Pharmacy Education (CPE) by the
Illinois Council of Health-System Pharmacists. The Illinois Council of Health-System Pharmacists
is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing
pharmacy education. The intended audience is pharmacy technicians.
This module will provide 2.5 contact hours of continuing pharmacy education credit for pharmacy
technicians.
ACPE Universal Activity Number: 0121-0000-21-003-H04-T | Type of Activity: Knowledge-based
Release Date: 4/1/21 | Expiration Date: 4/1/2024 (Must be completed by 3/31/2024 at 11:59PM CT)
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PHARMACY TECH TOPICS — JULY 2021
Meet the AuthorS
Sabra Douthit, PharmD
Sabra Douthit is the Medication Reconciliation Coordinator at Geisinger Medical Center (GMC) in Danville, PA. Dr.
Douthit received her Doctor of Pharmacy degree from Lake Erie College of Osteopathic Medicine (LECOM) School
of Pharmacy and had completed her pre-pharmacy studies at Gannon University in Erie, PA. She is active in the
medication reconciliation and transition of care workgroups in the Geisinger system and manages the medication
history technicians at GMC.
Daniel S. Longyhore, PharmD, EdD, BCACP
Daniel Longyhore is the System Director for Knowledge Management with Enterprise Pharmacy at Geisinger. As the
director for Knowledge Management, Dr. Longyhore is responsible for education-related endeavors for Enterprise
Pharmacy including directing experiential opportunities for students from eleven different schools of pharmacy and
an interprofessional rotation for fourth-year students at the Geisinger Commonwealth School of Medicine (GCSOM),
overseeing graduate pharmacy education and expanding the training opportunities in Geisinger, supporting the
professional practice and growth of pharmacists and pharmacy technicians in the system, developing pharmacy-
related certificate and diploma programming with GCSOM, and collaborating with other system leads to bring
medication information to Geisinger providers and patients. Dr. Longyhore earned his Doctor of Pharmacy, as
well as a master’s degree and Doctor of Education degree, from Wilkes University. He is licensed as a pharmacist in
Pennsylvania and is a Board-Certified Ambulatory Care Pharmacist.
FACULTY DISCLOSURE. It is the policy of the Illinois Council of Health-System Pharmacists (ICHP) to ensure balance and
objectivity in all its individually or jointly presented continuing pharmacy education programs. All faculty participating in any
ICHP continuing pharmacy education programs are expected to disclose any real or apparent conflict(s) of interest that may
have any bearing on the subject matter of the continuing pharmacy education program. Disclosure pertains to relationships
with any pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are
related to the subject matter of the topic.
The intent of disclosure is not to prevent the use of faculty with a potential conflict of interest from authoring a publication but
to let the readers know about the relationship prior to participation in the continuing pharmacy education activity. It is intended
to identify financial interests and affiliations so that, with full disclosure of the facts, the readers may form their own judgments
about the content of the learning activity.
The authors have no conflicts of interest and the module has been found to be balanced and objective. The content reviewers
have no real or apparent conflict(s) of interest that may have any bearing on the subject matter of this continuing pharmacy
education program.
NOTICE: Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes
in treatment and drug therapy are required. The author and the publisher of this work have checked with sources believed
to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at
the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors
nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the
information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions
or for the results obtained from use of such information.
Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers
are advised to check the product information sheet included in the package of each drug they plan to administer to be certain
that the information contained in this module is accurate and that changes have not been made in the recommended dose
or in the contraindications for administration. This recommendation is of particular importance in connection with new or
infrequently used drugs. Always refer to changes in federal law and any applicable state laws.
Pharmacy Tech Topics™ Steering Committee*
Margaret DiMarco Allen, PhD Amanda Daniels, BS, CPhT Jo Haley Patricia Wegner, BS Pharm,
Antoinette Cintron, CPhT Don Ferrill, PharmD, BCPS Scott Meyers, RPh, MS, FASHP PharmD, FASHP
Matthew Dandino, PharmD, BCPS Clara Gary, CPhT Ann Oberg, BS, CPhT
2 *Acting committee for 2019, responsible for selecting 2021 module topics.
A Comprehensive Review of Medication Reconciliation Practices for Pharmacy Technicians
A COMPREHENSIVE REVIEW OF MEDICATION
RECONCILIATION PRACTICES FOR PHARMACY
TECHNICIANS
For definitions of bolded terms, refer to She said she used metoprolol at home, but no one asked her
the glossary in Appendix A on page 16. the dose. With Mrs. Potts feeling better, she is sent home
with the instructions to resume her home medications.
About a week after her discharge, Mrs. Potts returns to
INTRODUCTION: the ER with the same symptoms as before. Since she
MED "WRECKED" restarted her home medication, including her previous
dose of metoprolol, she could not tolerate it and had to be
Medication errors are large contributors to illness, death, readmitted to the hospital.
and healthcare expense and have been identified as the Any time a patient’s list of medications is different
third leading cause of death in the United States (US).1 In between two or more settings (home, hospital, etc.) it
addition to this, the average hospitalized patient is subject 5
to at least one medication error per day and 1.5 million is a discrepancy. Discrepancies are common during
patients have injuries resulting from preventable adverse transitions of care and have the potential to impact
patient outcomes.6
2
drug events each year. Medication discrepancies are
common during transitions of care and have the potential If Mrs. Potts had a thorough medication reconciliation
to impact patient outcomes.3 The process of medication during her hospital admission, the chances of finding this
reconciliation can have a positive impact on the number discrepancy would have been more likely.
of unintended medication discrepancies; however, the
implementation of a thorough and consistent medication The logical benefits of medication reconciliation are
reconciliation process can be difficult and disjointed.3,4 often offset by the difficult process of starting a thorough
3,4
For example, consider the case of “Mrs. Potts.” Mrs. Potts and consistent reconciliation process. The purpose
is a 72-year-old woman with a medical history of high of this module is to highlight the medication history
blood pressure, arthritis, and heart failure. At home, she and medication reconciliation process for pharmacy
is taking acetaminophen 650 mg every 8 hours as needed technicians looking to build or update their technician
for arthritis pain, furosemide 20 mg by mouth once every responsibilities.
morning, and lisinopril 40 mg by mouth once every Test Your Knowledge #1
day for her blood pressure and heart failure. She is also Why should Mrs. Potts undergo the process of medication
taking metoprolol succinate for heart failure. Her dose of reconciliation?
metoprolol succinate was recently increased from 50 mg A. She has heart failure.
per day to 100 mg per day by her cardiologist. She goes B. She is elderly.
to the emergency room (ER) because she feels more tired C. She takes more than 3 medications at home.
than normal and is unable to walk short distances without D. She had a transition of care, from her home to the hospital.
being short of breath. Answer can be found on page 16.
When she is in the hospital, the doctors find she is slightly REGULATION OF MEDICATION
dehydrated. After giving her fluids, she is restarted on her RECONCILIATION
home medications and the symptoms do not return. What
the hospital staff does not know is Mrs. Potts' metoprolol The Joint Commission and National
dose while in the hospital does not match the dose she was Patient Safety Goals
taking at home.
The hospital thought she was taking metoprolol succinate The Joint Commission (TJC) is a nationally recognized
50 mg because they used old and outdated information. accrediting body which surveys health care facilities and
health-systems to review best practice recommendations.
3
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PHARMACY TECH TOPICS — JULY 2021
Accreditation through the Joint Commission makes 4. Provide the patient (or caregiver) with written
hospitals and health systems eligible for reimbursement information on the medications the patient should be
from Medicare and Medicaid programs. Within the Joint taking when he or she is discharged from the hospital
Commission accreditation standards are the National or at the end of an outpatient encounter.
7
Patient Safety Goals (NPSG). 5. Explain the importance of managing medication
information to the patient when he or she is discharged
The NPSG are developed through reports, observations, from the hospital or at the end of an outpatient
and expert opinions about the leading concerns for patient encounter.
safety. The goals identify where action should be taken to
reduce the risk of patient harm in healthcare. The Joint Commission recognized obtaining a medication
history was a difficult part of medication reconciliation.
Previous National Patient Safety Goals They had difficulty finding a general approach for
medication reconciliation that everyone could use. They
Recognition of the impact medication reconciliation has noted that there were many factors affecting the quality of
on patients was made by the Joint Commission in 2005 the information obtained in the medication history. If the
when it was listed as NPSG #8. At that time, the NPSG for medication history was poor, then the decisions made in
medication reconciliation had two requirements by which medication reconciliation would also be poor. The current
8 NPSG for medication reconciliation acknowledges this
hospitals and health systems were surveyed : and currently states that a good faith effort to obtain a
1. Put in place a process for obtaining and documenting medication history meets the intent of the goal.
a complete list of the patient’s current medications
upon the patient’s admission. This process includes World Health Organization's Standard
a comparison of the medications the patient is Operating Protocol
prescribed to those on the list.
2. A complete list of the patient’s medications is Outside of the US, medication reconciliation has the
communicated to the next provider of care when a attention of world leaders as adverse drug events are a
patient is referred or transferred to another setting, leading cause of sickness and death around the globe. The
service, practitioner, or level of care within or outside World Health Organization (WHO) has recognized the
the organization. importance of medication reconciliation in patient safety
Current National Patient Safety Goals and has developed a Standard Operating Protocol (SOP)
for hospital settings.
Between 2009 and 2010 the Joint Commission suspended The program is called the WHO Action on Patient Safety
the scoring of medication reconciliation during surveys (“High 5s”) initiative. The initiative is built upon seven
due to the lack of good strategies for accomplishing the 10
goal. When it returned in July 2011, medication principles for medication reconciliation :
reconciliation was moved up to National Patient Safety Goal 1. An up-to-date and accurate patient medication list is
#3. It remains at #3 today.9 The Joint Commission currently essential to ensure safe prescribing in any setting.
9
lists the following as meeting its elements of performance : 2. A formal structured process for reconciling
1. Obtain information on the medications the patient medications should be in place for all points of care.
is currently taking when he or she is admitted to 3. Medication reconciliation on admission is the foundation
the hospital or is seen in an outpatient setting. This for reconciliation throughout the episode of care.
information is documented in a list or other format 4. Medication reconciliation is inserted into existing
that is useful to those who manage medications. processes for medication management and patient flow.
2. Define the types of medication information to be 5. The process of medication reconciliation is one of
collected in non-24-hour settings. shared accountability with staff aware of their roles
3. Compare the medication information the patient and responsibilities.
brought to the hospital with the medications ordered 6. Patients and families are involved in medication
for the patient by the hospital in order to identify and reconciliation.
resolve discrepancies. 7. Staff responsible for reconciling medications are
trained to take a best possible medication history
(BPMH) and reconcile medications.
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