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Primary Care MedRec Guide

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An Overview of Medication Reconciliation

Medication reconciliation is a formal process in which healthcare providers work together with patients, families, and other care providers to ensure that accurate and complete medication information is communicated consistently across transitions of care. MedRec requires a systematic and comprehensive review of all the medications a patient is taking to allow careful evaluation of any medications that are being added, changed, or discontinued.12

Completing MedRec in primary care involves 4 main activities:

  • Collecting and documenting an accurate and up-to-date medication list (the Best Possible Medication History [BPMH])
  • Comparing the BPMH with information in the patient's medical records and identifying discrepancies (i.e., differences between various sources of medication information)
  • Correcting the discrepancies as appropriate through discussion with the primary care provider and the patient and then updating the BPMH with the resolved discrepancies, thereby creating a reconciled list
  • Communicating the resulting medication changes to the patient and verifying the patient's understanding of his or her medication regimen

...making sure the right information is communicated about a patient's medications each time the patient moves throughout the healthcare system

The cornerstone of MedRec is a comprehensive medication list known as the BPMH. Collection of the BPMH requires a structured process of interviewing the patient or a caregiver to ascertain all medications that the patient is taking (both prescribed and nonprescribed), confirming the patient's actual medication use, and verifying that information against other sources of medication information for the patient. The BPMH can serve as the foundation for all future medication-related decisions, i.e., the starting point of medication management.

Medication management is an overarching concept that describes the delivery of patient-centred care to optimize safe, effective, and appropriate drug therapy. This care is provided through collaboration with patients and their healthcare teams.13

Figure 1: The role of MedRec within context of medication management

The Case for MedRec

The overarching goal of MedRec is to prevent adverse drug events from occurring by collecting an accurate and comprehensive medication list and using this list to make appropriate prescribing decisions for a patient. A critical step of the MedRec process is to communicate to the patient and to all the healthcare providers involved in the patient's care any changes made to a patient's pre-existing medication regimen. Accurate communication about a patient's medication information is especially critical at transition points within the healthcare system (e.g., hospital discharge to home). Effective communication can reduce the chance of causing or perpetuating adverse drug events.

An adverse event is an unexpected and undesired incident that is directly associated with the care or services provided to a patient. When the event involves injury from a medication or lack of an intended medication, it is called an adverse drug event (ADE). This term encompasses adverse drug reactions and harm from medication incidents.14

Figure 2: Relationship between medication errors and adverse drug events15

A medication error or incident is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include problems that occur during prescribing, order communication, compounding, dispensing, distribution, administration, education, monitoring, and use of a medication or problems with product labelling and packaging or with drug nomenclature.16

Several methods are available to report medication incidents. Reports of medication incidents are confidential, but analysis of and learning from these reports helps in designing safer systems and preventing similar mistakes from happening in similar situations.

Report a medication incident
Practitioner Reporting
Healthcare Professional - (e.g., nurse, pharmacist, physician)
Consumer Reporting
Preventing harm from medication incidents is a responsibility of health professionals. Consumers like you can also play a vital role.

The Need for MedRec
  • A comparison of recorded medications in physicians' records and reported medication use by patients showed discrepancies in 76% of cases.17
  • The rate of adverse drug events in ambulatory care was estimated at 27.4 per 100 patients, and 13% of these events were classified as serious.18
  • More than 1 in 9 emergency department visits are due to drug-related adverse events, 68% of which are thought to be preventable.19
  • A comparison between patients' electronic medical record (EMR) lists and a pharmacy's medication fill histories found
    • an average of 6 discrepancies per patient
    • 41% of patients with an inactive medication recorded on their EMR profile2
  • A sample of more than 600 clients admitted to home care showed that 45% of eligible clients had at least one medication discrepancy requiring clarification by a physician or other primary care practitioner.20
  • In one Canadian family health team office, an audit of charts of patients taking 4 or more medications showed that only 1 of 86 EMR-based medication lists was accurate when compared with a comprehensive medication list based on a patient interview and collection of a medication history.21
The Benefits of MedRec
  • MedRec conducted in a primary care clinic significantly reduced (from 26% to 6%) the proportion of visits with missing medication lists and reduced prescription medication errors by more than 50%.9
  • In 4 academic primary care clinics, completeness of medication lists improved from 20.4% to 50.4% (p < 0.001) after a MedRec intervention was implemented. Patient participation in the MedRec process increased from 13.9% to 33% (p < 0.001).11
  • Among patients who received MedRec 3 to 7 days post discharge, there was a statistically significant decrease in readmission rates at days 7 and 14.22

MedRec across the System

MedRec is a system-level approach to reducing harm. To be most effective, MedRec should be implemented in all care settings where changes may be made to patients' medication regimens. The processes implemented in the various care settings will differ, but the aim of reducing the potential for harm remains consistent.

MedRec should take place in the following settings:

  • hospitals
  • long-term care homes
  • patients' homes (via home care services)
  • ambulatory clinics
  • family physician and nurse practitioner offices
  • community pharmacies

Refer to Appendix 1 for MedRec processes in other healthcare sectors.

The inputs to and outputs from each sector or healthcare setting can serve as the basis for MedRec in the next care setting. For example, a medication review (e.g., MedsCheck) completed by the community pharmacy may serve as the basis for a BPMH in the hospital.

Every institution's discharge is another's admission
-Author unknown

Transitions and Interfaces of Care

Transitions of care are points in the trajectory of care with vulnerability to adverse drug events. Such vulnerabilities arise because as patients transition from one healthcare setting to another, the responsibility to ensure safe medication use is transferred from one healthcare provider to another.11,23,24

Examples of transitions of care include:

  • Admission to hospital from the patient's home environment
  • Transfers between facilities (e.g. hospital to long-term care)
  • Discharge from hospital to the patient's home
  • Referral for homecare services from the primary care provider
  • Admission to long-term care from the patient's home
  • Interactions within primary practice settings (e.g., visits to family medicine practice, walk-in clinic, or a specialist)

Each transition of care is an opportunity for MedRec and an opportunity to improve communication about the patient's medications to enhance medication safety.

Figure 3: Transition points within primary care settings

Primary care may occur in a variety of settings. For example, a patient may receive care at home, with medication management support by a home care organization and intermittent visits to the family physician, nurse practitioner, or outpatient clinic. If changes to medications are not clearly communicated back to the patient and/or the receiving organization, the potential for medication-related adverse events may exist.

  • 16% of primary care physicians say hospitals send them information needed for follow-up care within 48 hours of a patient being discharged
  • 26% say they always receive a comprehensive report from specialists who have seen their patients, and 11% of them say these reports are timely

How do Canadian primary care physicians rate the health system?
Health Council of Canada, 2013

Support for MedRec

Accreditation Canada has been incorporating MedRec standards into its Required Organizational Practices (ROPs) since 2005 and has been increasing and expanding requirements across sectors. Currently, Accreditation Canada requires MedRec to be completed (to varying degrees) in acute care, long-term care, home care, and primary care.

Refer to Accreditation Canada's Required Organizational Practice Handbook for a complete list of requirements.

The Ontario Ministry of Health and Long Term Care (MOHLTC) vision of system-wide quality improvement identifies MedRec as a priority by including metrics related to MedRec and integrated care across patient care settings in the quality improvement plan program and through support of the Health Links program.

The MOHLTC provides overall vision, strategy, and direction on QIPs. Click on this MOHLTC link ( for more information on:

Health Links were created by the Ontario MOHLTC in 2012 to serve the small segment (approximately 5%) of the population that uses about 66% of healthcare resources. The focus of this program is on improving coordination of care and the overall patient experience for seniors and others with complex medical conditions.

Health Links will encourage greater collaboration between existing local healthcare providers, including primary care practitioners, specialists, hospitals, long-term care facilities, home care agencies, and other community supports. With improved coordination and information-sharing, patients will receive faster care, will spend less time waiting for services, and will be supported by a team of healthcare providers at all levels of the healthcare system. MedRec has been identified as one of the leading evidence-informed practices supporting many of these improvements at both the patient and the system level.

Health Quality Ontario has demonstrated support of MedRec through its primary care measurement framework, quality improvement compass, and support of Health Links.

Figure 4: Medication Communication Failures Impact Everyone!

©2012 Developed by ISMP Canada for the National MedRec Strategy Available for download here.

Medication reconciliation is not just for doctors working in institutions. Family doctors have an ongoing relationship with their patients and are often the custodian of the medication list. In this way, medication reconciliation may be viewed as an ongoing process (e.g. whenever the patient visits, when the pharmacy calls, when incoming records from other specialists are received) involving family doctors and other key stakeholders within the patient's circle of care.

The Canadian Medical Protective Association