01Principles and purposeThe professional or clinical skill and the decisions it supports.
A medicine history asks what someone was taking. Reconciliation establishes which of those medicines should be ordered now, explains intentional differences and resolves unintended ones. The process requires comparison between sources because no single list is invariably complete. A GP repeat entry may include a medicine that the patient stopped; a pharmacy record may show dispensing without proving use; a discharge letter may omit a specialist injection. Each source answers a different question. The aim is a clinically coherent account of exposure and an accurate current plan, not simply agreement between two screens.
Medication errors can arise during prescribing, dispensing, administration, monitoring and communication. Some are intercepted before exposure; others cause no apparent harm; some cause injury that emerges only later. The first response protects the person, while subsequent investigation examines how the error became possible. A systems approach considers workload, interface design, handovers and unavailable medicines alongside individual decisions. It supports accountability by making the process visible and improvable. Repeatedly telling staff to be more careful is unlikely to resolve a design that repeatedly offers an unsafe frequency or conceals a missed dose.
Preserve where information came from and how current it is. For example, a specialist letter establishes the intended dose at the date it was written, while an administration record establishes what a care service gave on particular days. Neither alone resolves a later change made by telephone. Record the remaining uncertainty and seek the source most likely to answer it. When a high-risk discrepancy cannot be resolved immediately, a responsible clinician must weigh the harms of giving and withholding the medicine and write an explicit interim plan. Silence in the record is not a safe interim decision.
Key points
- Reconciliation compares actual pre-admission treatment with current orders and resolves the differences; transcription alone is insufficient.
- Use the patient’s account and other reliable sources, including dispensing and administration records when needed.
- Identify time-critical medicines immediately; do not wait for the full medicine history before preventing a harmful omission.
- In acute settings, complete reconciliation within 24 hours of admission, or sooner when clinically necessary.
- In primary care, reconcile within one week of receiving discharge information and before a new prescription or supply.
- For every change, communicate the reason, intended duration, monitoring owner and any restart criteria.
02Situations and prioritiesThe context, relevant information and actions that matter most.
An omitted essential medicine and an unnecessary continued medicine can both cause harm. Ask whether a missing item was intentionally withheld, accidentally left off or unavailable. Conversely, consider whether a new inpatient drug addressed a temporary problem that has resolved. The absence of a written reason should trigger clarification rather than an assumption that the change was deliberate.
Strength, formulation, route and interval are distinct sources of discrepancy. A medicine may appear present on both lists while one version is immediate-release and the other modified-release. Weekly prescriptions can become daily through a default setting. Administration times can matter for symptom control even when the total daily dose matches.
Patches, injections, eye drops, inhalers and purchased products are easy to overlook when the interview focuses on tablets. Ask specifically about medicines supplied by another clinic and those taken only occasionally. Establish when long-acting treatment was last administered to avoid duplicate dosing after transfer.
Risk increases when several teams assume another has checked the medicines. Emergency department boarding, ward transfers, care-home admission and discharge each change the people and systems responsible for administration. Make ownership explicit; a prescription visible in one part of the record may not yet be available to the person giving it.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Best possible medicines history - Why
- Reconstruct the intended regimen and the patient’s actual use.
- Interpretation and limitations
- Ask the patient or a knowledgeable carer, then compare reliable records appropriate to the situation. Include dose, formulation, route, usual times, indications and last doses. Explain discrepancies respectfully: patients may have made deliberate adjustments because of side effects that never reached the repeat-prescribing record.
- 02
Administration and dispensing evidence - Why
- Distinguish prescribed treatment from doses actually received.
- Interpretation and limitations
- Inspect medication administration records, dispensing history and the patient’s own supplies. Counted tablets can support but do not prove an exposure estimate. For suspected error, establish exact times and amounts as far as possible and identify uncertainty explicitly; do not convert an assumed schedule into a factual administration history.
- 03
Clinical consequence assessment - Why
- Determine which discrepancy could harm the patient soonest.
- Interpretation and limitations
- Review symptoms, observations and relevant tests in relation to the medicine involved. Missed Parkinson’s treatment may affect movement and swallowing; interruption of insulin in type 1 diabetes can become dangerous. Prioritise the next necessary action rather than processing the list in alphabetical order.
- 04
Change attribution - Why
- Identify the intended rationale for every difference between lists.
- Interpretation and limitations
- Classify a difference as an explained intentional change, an undocumented change requiring clarification or an unintended error. Contact the responsible team when the rationale matters. The classification may change as evidence arrives, so preserve the source and timing of each clarification in the record.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseCorrect a weekly medicine before administrationA woman admitted with a fracture usually takes methotrexate 15 mg orally each Friday for rheumatoid arthritis. Her medicine card and community pharmacy confirm this. The admission chart says 15 mg daily, and no hospital doses have yet been given.+
- 1Compare the current order with the verified indication and schedule. The daily frequency is inconsistent with this patient’s established weekly autoimmune regimen and creates an imminent overdose risk. Stop the incorrect order before the next administration round.
- 2Confirm the last home dose and inspect the administration record to establish whether exposure occurred. In this case no hospital dose has been given; if uncertainty remains, treat the exposure history as unresolved and obtain urgent advice rather than assuming interception was complete.
- 3Ask the responsible prescriber to enter the correct weekly instruction with the day written in full, after assessing whether acute illness or the admission itself requires temporary withholding. Reconciliation confirms the baseline regimen; it does not automatically authorise continuation in every new clinical circumstance.
- 4Explain the discrepancy and corrected plan to the patient and nursing team. Verify the tablet strength and ensure that the discontinued daily order cannot remain active elsewhere in the electronic system or on a paper chart.
- 5Check the next scheduled administration and report the intercepted error through the local learning process. Investigate how the daily frequency was selected and whether defaults or order-set design could expose other patients to the same mistake.
02Admission workflowProtect essential treatment while building the listA newly admitted patient has several long-term medicines and the complete history is not yet available.+
- 1Identify immediate needs, allergies and time-critical treatment at the first assessment. Establish the next due dose and how to obtain the medicine. Do not defer urgent continuity solely because routine pharmacy reconciliation is scheduled for the following morning.
- 2Create the best available history using appropriate sources, then compare it item by item with admission orders. Check actual administration times, recent changes and products obtained outside the usual GP record.
- 3Review each proposed continuation against the acute illness. A medicine may need a route change, dose adjustment or temporary hold, but write the reason and reassessment criteria rather than leaving an unexplained omission.
- 4Complete and communicate the reconciled plan within the required acute-setting timeframe, escalating unresolved high-risk items sooner. Name the person who will pursue outstanding information and establish a safe interim plan until it is obtained.
03Discharge workflowTransfer a plan that can be continued safelyThe patient is leaving hospital with medicines started, stopped or temporarily withheld during admission.+
- 1Compare the discharge list with both pre-admission treatment and the final inpatient plan. Identify new medicines, altered doses, resolved temporary treatments and withheld medicines awaiting reassessment. Remove accidental duplication between replacement and original products.
- 2For each difference, state why it occurred and what happens next. Give the intended course, stop date or review interval; identify the clinician responsible for laboratory monitoring and any clinical conditions needed before restart.
- 3Explain the plan using the patient’s actual medicines and ask them to describe how they will take the next doses. Check supply, administration aids and the ability of carers or the receiving service to implement the instructions.
- 4Send the information to the professionals continuing care and verify urgent handover where delay would cause harm. In primary care, update and reconcile the received discharge information before generating another prescription, within the one-week standard.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- After an error with possible exposure, determine the observation period and tests from the medicine, amount, time and patient factors. Lack of symptoms at discovery does not exclude delayed toxicity, so obtain medicine-specific advice where needed.
- Check that the corrected order reaches every administration system. Removing one duplicate prescription may leave another active in a separate ward, infusion or discharge record.
- Review unresolved discrepancies at handover with a named owner and expected resolution time. A note saying pharmacy to check is insufficient when the next dose will be due before pharmacy assessment.
- Use learning reports to assess recurrence and whether a change worked. An effective intervention should alter the conditions producing the error, such as unsafe defaults, unavailable stock or unclear responsibility, rather than merely increase documentation.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Reconciliation and review differ
Reconciliation establishes the accurate current plan; medication review examines whether that plan remains appropriate. They overlap in practice, but a perfectly reconciled list can still contain unnecessary or harmful treatment. State which decision has actually been completed.
Patient involvement adds evidence
A patient may know that an apparently omitted medicine was stopped after a telephone call, or that a labelled twice-daily dose is actually taken once. Their explanation can resolve the discrepancy and expose a communication problem requiring correction elsewhere.
Near misses reveal system weakness
An intercepted error still shows a pathway capable of producing harm. Examine why it was caught and whether that protective step is reliable. A fortunate colleague’s memory is a less dependable barrier than a prescribing system that prevents an inappropriate frequency.
Availability is part of treatment
A correct prescription has no effect if the medicine cannot reach the patient at the required time. Stock location, access to the patient’s own supply and an alternative administration route may be the decisive actions in preventing a time-critical omission.
07Common pitfallsFrequent interpretation and management errors.
- 01
Equating the newest electronic list with the correct list ignores the possibility that a recent transfer introduced the discrepancy.
- 02
Automatically restarting every home medicine can be unsafe during acute illness; confirm the history and make a separate continuation decision.
- 03
Recording an incident before assessing the patient reverses the immediate priority when a potentially harmful dose has already been administered.
- 04
Explaining a change verbally without updating the repeat record permits the discontinued treatment to be supplied again at the next request.