What interventions improve the accuracy and continuity of medication lists as patients move between healthcare providers and settings?

What is the aim of this review?

We aimed to find out if medication (medicine) reconciliation improves medication discrepancies, outcomes affecting patients specifically and healthcare utilisation as patients move or transition between healthcare providers (e.g. pharmacists, nurses, doctors) and settings (e.g. emergency department, primary care). Medication reconciliation involves building a complete list of a person's medications, checking them for accuracy, reconciling and documenting any changes. Medication reconciliation is recommended as an intervention to improve the accuracy of medication information at transitions. All care transitions (e.g. home to hospital, ED to hospital ward) and patient types (e.g. children, older people) were open for inclusion in the review.

Key messages

Review authors collected and analysed all relevant studies to answer this question and found 25 studies. This review found unreliable evidence that interventions reduced the number of discrepancies in patients' medications as they transition between different healthcare settings. Similarly, the benefit in terms of clinically orientated outcomes (e.g. admission to hospital) was uncertain.

What was studied in the review?

We included studies that used a randomised design where people were randomly put into one of two or more treatment groups. The main outcome of interest was whether the possibility of any discrepancies in a patient's medication list was reduced following the intervention. Other outcomes that were assessed in the review were the intervention's impact on the number of medication discrepancies, medication side effects, preventable medication side effects, hospital usage (e.g. emergency department visits and readmission to hospital), negative/adverse impacts of the intervention and resource usage.

What are the main results of the review?

The review authors found 25 studies conducted in eight different countries in hospital or immediately related settings. Twenty-three studies were primarily pharmacist delivered, one was an electronic reconciliation tool and one medical record changes. Studies mainly included older people prescribed multiple medications.

While many studies reduced the presence of at least one medication discrepancy in people receiving the intervention, we were uncertain whether reconciliation reduced discrepancies as the reliability of the evidence was very low. The evidence for the intervention's effect on the number of discrepancies and on clinical outcomes such as actual and preventable medication side effects, combined measures of healthcare utilisation and unplanned readmissions to hospital itself was varying with evidence ranging from moderate to low or very low reliability.

How up-to-date is this review?

The review authors searched for studies that had been published up to January 2018.

Authors' conclusions: 

The impact of medication reconciliation interventions, in particular pharmacist-mediated interventions, on medication discrepancies is uncertain due to the certainty of the evidence being very low. There was also no certainty of the effect of the interventions on the secondary clinical outcomes of ADEs, PADEs and healthcare utilisation.

Read the full abstract...

Transitional care provides for the continuity of care as patients move between different stages and settings of care. Medication discrepancies arising at care transitions have been reported as prevalent and are linked with adverse drug events (ADEs) (e.g. rehospitalisation).

Medication reconciliation is a process to prevent medication errors at transitions. Reconciliation involves building a complete list of a person's medications, checking them for accuracy, reconciling and documenting any changes. Despite reconciliation being recognised as a key aspect of patient safety, there remains a lack of consensus and evidence about the most effective methods of implementing reconciliation and calls have been made to strengthen the evidence base prior to widespread adoption.


To assess the effect of medication reconciliation on medication discrepancies, patient-related outcomes and healthcare utilisation in people receiving this intervention during care transitions compared to people not receiving medication reconciliation.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, seven other databases and two trials registers on 18 January 2018 together with reference checking, citation searching, grey literature searches and contact with study authors to identify additional studies.

Selection criteria: 

We included only randomised trials. Eligible studies described interventions fulfilling the Institute for Healthcare Improvement definition of medication reconciliation aimed at all patients experiencing a transition of care as compared to standard care in that institution. Included studies had to report on medication discrepancies as an outcome.

Data collection and analysis: 

Two review authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. Study-specific estimates were pooled, using a random-effects model to yield summary estimates of effect and 95% confidence intervals (CI). We used the GRADE approach to assess the overall certainty of evidence for each pooled outcome.

Main results: 

We identified 25 randomised trials involving 6995 participants. All studies were conducted in hospital or immediately related settings in eight countries. Twenty-three studies were provider orientated (pharmacist mediated) and two were structural (an electronic reconciliation tool and medical record changes). A pooled result of 20 studies comparing medication reconciliation interventions to standard care of participants with at least one medication discrepancy showed a risk ratio (RR) of 0.53 (95% CI 0.42 to 0.67; 4629 participants). The certainty of the evidence on this outcome was very low and therefore the effect of medication reconciliation to reduce discrepancies was uncertain. Similarly, reconciliation's effect on the number of reported discrepancies per participant was also uncertain (mean difference (MD) –1.18, 95% CI –2.58 to 0.23; 4 studies; 1963 participants), as well as its effect on the number of medication discrepancies per participant medication (RR 0.13, 95% CI 0.01 to 1.29; 2 studies; 3595 participants) as the certainty of the evidence for both outcomes was very low.

Reconciliation may also have had little or no effect on preventable adverse drug events (PADEs) due to the very low certainty of the available evidence (RR 0.37. 95% CI 0.09 to 1.57; 3 studies; 1253 participants), with again uncertainty on its effect on ADE (RR 1.09, 95% CI 0.91 to 1.30; 4 studies; 1363 participants; low-certainty evidence). Evidence of the effect of the interventions on healthcare utilisation was conflicting; it probably made little or no difference on unplanned rehospitalisation when reported alone (RR 0.72, 95% CI 0.44 to 1.18; 5 studies; 1206 participants; moderate-certainty evidence), and had an uncertain effect on a composite measure of hospital utilisation (emergency department, rehospitalisation RR 0.78, 95% CI 0.50 to 1.22; 4 studies; 597 participants; very low-certainty evidence).