Background Medication reconciliation (MR) is the process when medication history is reconciled with subsequent medicine orders in the electronic medication system. Documentation of this is important, as it informs other healthcare personnel that the physician has considered the medication and that the nurse can safely administer the medication.
The hospital department management receives weekly auto-generated reports showing the percentage of patient records with documentation of MR within the first 24 hours of admission. According to the local guidelines, it is the physician’s responsibility to perform the reconciliation and documentation afterwards. The reports, however, do not tell if the reconciliation was actually performed or was done incorrectly.
Purpose To investigate to what extent MR is actually performed despite documentation and, if performed, is actually documented correctly. Furthermore, to investigate if the experience of the physician influenced the results.
Material and methods The study was set in a short-term admission unit. Data were collected for 6 months (February to July 2017). On weekdays clinical pharmacists reviewed the medication for the admitted patients, and documented if the MR was documented correctly and evaluated if the reconciliation was actually done. If the reconciliation was not documented, the pharmacist evaluated if it was not performed or if it was performed but not documented.
Results The pharmacists reviewed 815 patients in total, of which in 66 cases (8%) the physician had carried outMR, but not documented it. In 20 cases (2.5%) the physician had documented a MR without having performed it. In 36 cases (4.4%), it was not possible for the physician to do a MR due to incomplete data. Data were explored to see if new physicians in the ward affected the result, though no association was found.
Conclusion The reports showing the percentage of MR performed, does not tell the whole story. In 8% of the cases the physician actually had done the MR, but forgot to document it in the medication record, and in 2.5% of the cases the physician had documented a MR without having performed it.
No conflict of interest