By Brian Wenger, PharmD, BCPS

Medication reconciliation is an established part of medication safety in pharmacy practice. Health systems invest substantial time and resources in obtaining accurate medication histories, reconciling home medications at admission, and building these processes into electronic health records (EHRs). 

However, hospitalization itself can substantially change a patient’s medication regimen. At discharge, those changes must be translated into a plan that is clinically appropriate, accurate, understandable, accessible, and executable outside the hospital. That makes discharge another critical point for medication reconciliation.

One common scenario involves a patient whose antihypertensives (blood pressure medications) were held during admission because of persistently low blood pressure. Unless those medications are deliberately reevaluated at discharge, the patient’s prior doses may unintentionally reappear on the medication list.

Similar problems occur when medications titrated during hospitalization are prescribed at prior-to-admission doses at discharge, when inpatient formulary substitutions are carried forward unintentionally, or when a medication held for several days is restarted without careful consideration. Electronic discharge workflows can make reconciliation appear complete without ensuring the final regimen has undergone a comprehensive medication-focused review.

More than comparing two lists

Admission medication reconciliation generally centers on what the patient was taking before hospitalization. Discharge reconciliation asks a different question, which is what the patient should take now and whether every part of the discharge plan accurately reflects that decision.

Published studies continue to show opportunities for intervention at discharge. In a 2024 prospective quality-improvement pilot of pharmacist-led discharge medication reconciliation, pharmacists identified 40 errors among 31 patients, and 68% of patients had at least one identified error. Duplication of therapy and medication-access barriers were the two most common categories. Earlier studies identified discrepancies involving omitted medications, inappropriate doses, unreconciled orders, duplicate therapy, and medications for chronic disease management.

A thorough discharge review goes beyond confirming that medications appear on a list. It may require reviewing inpatient medication administration, prior-to-admission regimens, laboratory and clinical data, and the intended post-discharge plan. 

Questions at this stage may include:

• Whether a medication held during hospitalization should be resumed
• Whether a dose changed during admission should remain changed
• Whether antimicrobial selection and duration align with the intended treatment course
• Whether a taper is prescribed correctly
• Whether new prescriptions, discontinued medications, and patient-facing instructions tell the same story

These are medication-management questions. Pharmacists are well-positioned to identify them before the patient crosses the hospital threshold.

A safe and executable medication plan

Clinical appropriateness is only one part of a successful transition. A well-selected medication provides little benefit if a patient cannot obtain it. A prescription may require prior authorization, be unaffordable, be unavailable at the intended pharmacy, or be sent to the wrong location. Duplicate prescriptions or confusing directions add further uncertainty.

For these reasons, medication access should be treated as part of medication safety at discharge. When an access barrier changes what a patient actually takes, the intended regimen and the patient’s real-world regimen no longer match.

Addressing these issues does not require a hospital to operate an outpatient pharmacy. Pharmacists working in inpatient or transitions-of-care roles can identify clinical, insurance, affordability, and logistical barriers, then collaborate with prescribers, community pharmacies, insurers, patients, and the rest of the care team to resolve them. This gives health-system pharmacy departments an opportunity to reconsider a traditional boundary, the idea that inpatient pharmacy responsibility ends when discharge prescriptions are signed.

Building discharge reconciliation into a pharmacy service

Resources are a common barrier to pharmacist involvement at discharge. Not every organization can immediately establish a dedicated transitions-of-care pharmacist position. What’s more, not every patient requires the same level of pharmacist review. 

Developing a discharge medication reconciliation service does not have to begin with a new full-time position.

A practical first step is defining the problem the service is meant to solve. That might be medication-related readmissions, recurring discharge prescribing errors, delays caused by medication access, or breakdowns in transitions to post-acute facilities. The desired outcome can then inform the service’s design.

Many clinical pharmacists already participate in admission medication reconciliation and can incorporate targeted discharge review into their workflows. When resources limit a broader review, organizations can develop criteria to prioritize patients based on medication risk, complexity, service line, discharge destination, or other locally relevant factors.

The EHR should support the process rather than define it. Organizations may create discharge work queues or other mechanisms to identify patients approaching discharge, as well as standardized documentation templates and pathways for escalating identified issues.

The work should also be measured. Pharmacy departments can track the number and types of interventions, medication discrepancies identified, access barriers resolved, intervention acceptance, and recurring system failures. Depending on available analytics infrastructure, these data points can be paired with outcomes such as emergency department utilization, readmissions, or other quality measures.

Those findings should not remain solely within the pharmacy department. Medication-safety committees, readmission initiatives, quality-improvement groups, and hospital leadership are important venues for understanding how medication-related problems at discharge affect broader organizational goals.

Over time, this approach can turn discharge medication reconciliation from an added pharmacist task into a defined service line with its own workflow, documentation, quality measures, expertise, and opportunities for expansion.

Closing the gap

Medication reconciliation is not complete simply because an accurate medication history was obtained at admission or a provider completed the required discharge workflow. Hospitalization changes medication therapy. Discharge then transfers responsibility for that changed regimen from a highly monitored environment to patients, caregivers, community pharmacies, ambulatory clinicians, and post-acute care facilities. That transition deserves its own deliberate medication-safety infrastructure.

The appropriate model differs across organizations. Some health systems may begin with a targeted review by existing clinical pharmacists. Others may develop centralized workflows, technology-supported prioritization, or dedicated transitions-of-care pharmacy services. 

The first step is simpler. Pharmacy leaders can start by examining how medication reconciliation is handled at the end of hospitalization.

If no one owns that final medication-focused review, there may be a gap worth closing.

References

Bishop, M. A., et al. (2015). Reducing errors through discharge medication reconciliation by pharmacy services. American Journal of Health-System Pharmacy.

Kilcup, M., et al. (2013). Postdischarge pharmacist medication reconciliation: Impact on readmission rates and financial savings. Journal of the American Pharmacists Association.

Walker, P. C., et al. (2009). Impact of a pharmacist-facilitated hospital discharge program: A quasi-experimental study. Archives of Internal Medicine.

Zheng, L., et al. (2024). Impact of pharmacist-led discharge medication reconciliation on error and patient harm prevention at a large academic medical center. Journal of the American College of Clinical Pharmacy.