What are our four stages of medicine reconciliation? A Comprehensive Guide

October 11, 2025 •

3 min read

According to government data, more than 40 percent of medication errors are believed to result from inadequate reconciliation during transitions of care. Understanding what are our four stages of medicine reconciliation is therefore a critical step for healthcare professionals to ensure patient safety and prevent adverse drug events.

Quick Summary

This guide breaks down the essential four-stage process of medication reconciliation, detailing how healthcare providers obtain, verify, and compare a patient's medication history to ensure accuracy during care transitions. It covers the resolution of discrepancies and proper communication of the final medication plan to all involved parties, thereby reducing the risk of medication errors.

Key Points

Obtain BPMH: The initial step of gathering a comprehensive list of all current medications, including OTC and supplements, from the patient and other sources.
Confirm Accuracy: Verify the collected medication list against at least one other source, like pharmacy records or other providers, to ensure its completeness and accuracy.
Reconcile Lists: Compare the confirmed BPMH with new medication orders to identify and resolve discrepancies, documenting all decisions with the prescriber.
Reduce Errors: Following the four-stage process is proven to reduce medication errors, adverse drug events, and hospital readmissions by preventing communication breakdowns.
Involve Patients: Patient education and involvement are crucial for the process's success, as they are a primary source of information and an advocate for their own care.
Communicate Plan: Ensure the updated medication list and instructions are clearly communicated to the patient and all subsequent healthcare providers, particularly during discharge.

The Foundation of Patient Safety

Medication reconciliation is a formal process designed to prevent medication errors by ensuring a patient's medication list is accurate and complete at all transitions of care. This process is crucial because movements between healthcare settings—such as admission, transfer, or discharge—are particularly vulnerable periods for medication-related errors. Implementing a standardized approach helps to catch potential issues like duplication, omissions, incorrect dosages, and adverse drug interactions.

Following a structured process is a best practice recommended by organizations like the Joint Commission and the Agency for Healthcare Research and Quality (AHRQ). The steps below outline the gold standard four-stage method for a safe and effective reconciliation.

Stage 1: Obtain the Best Possible Medication History (BPMH)

The first and most vital stage is gathering a comprehensive and accurate list of all medications the patient is currently taking. This list, known as the Best Possible Medication History (BPMH), should be collected early in the care transition. Obtaining a reliable BPMH involves more than just a quick self-report.

Key actions in this stage include:

Interviewing the patient and/or their caregiver: Direct communication is a primary information source. Open-ended questions are recommended.
Gathering information from multiple sources: Supplement patient reports with data from medical records, referral letters, and pharmacy systems.
Documenting specific details: Record medication name, dosage, route, frequency, and last dose time for each drug.
Including all drug types: Ensure the BPMH includes prescription, over-the-counter, herbal, and vitamin supplements.

Stage 2: Confirm the Accuracy of the BPMH

After compiling the initial BPMH, verify its accuracy to ensure completeness and reliability. This verification step is a crucial check for inconsistencies. Verification can involve cross-referencing with other providers, utilizing EHRs (while being aware of their limitations), and reconfirming details with the patient.

Stage 3: Reconcile the Medication Lists

This stage involves comparing the confirmed BPMH with newly prescribed or ordered medications to identify and resolve discrepancies. Discrepancies are differences between the lists and can be intentional or unintentional. Resolving these involves identifying issues like omissions or dose changes, making clinical decisions often with pharmacist input, and thoroughly documenting all changes and the reasoning behind them.

Stage 4: Communicate the Finalized Medication Information

The final stage ensures all parties, including the patient, are aware of the updated medication plan. This is vital during care transitions like hospital discharge. Key communication steps include sharing the reconciled list with the next provider and educating the patient and family on the updated plan, including purpose, dosage, and side effects. Patients should be advised to keep and share their updated medication list.

Comparison of Reconciliation during Admission vs. Discharge


Feature	Admission Reconciliation	Discharge Reconciliation
Goal	Establish the most accurate baseline of medications the patient was taking prior to hospitalization.	Create a safe and effective medication regimen for the patient's home environment or next care setting.
Focus	Gathering a comprehensive BPMH from all available sources to inform inpatient orders.	Updating the patient's pre-admission list to reflect changes made during the hospital stay.
Risk	Errors of omission (missing meds) or continuation of meds that should be paused.	Errors related to new prescriptions, incorrect dosages, or failing to restart previously paused medications.
Key Action	Obtaining and confirming the BPMH.	Providing the patient with a clear, updated medication list and instructions.

Challenges and Best Practices in Medication Reconciliation

Medication reconciliation faces challenges such as time constraints, limited resources, technological gaps, and lack of standardized processes. Best practices to overcome these include defining clear roles, utilizing technology (while recognizing its limitations), auditing and providing feedback, enhancing inter-professional collaboration, and educating patients.

Conclusion

Medication reconciliation is a vital component of patient safety. By following the four stages—obtaining the BPMH, confirming accuracy, reconciling discrepancies, and communicating the plan—healthcare providers can significantly reduce medication errors. A structured, collaborative approach, supported by technology and continuous monitoring, is essential for effective reconciliation across all care transitions, leading to improved patient outcomes.

For more information on patient safety, visit {Link: AHRQ https://www.ahrq.gov/}.

Frequently Asked Questions

Medication reconciliation is important because it significantly reduces the risk of medication errors, which can lead to adverse drug events, increased healthcare costs, and patient harm. It ensures continuity of care as patients move between different healthcare settings.

While the process involves collaboration across a multidisciplinary team, including physicians, pharmacists, and nurses, the responsibility for reconciling medication orders often lies with the prescribing provider. However, policies should clearly define roles for everyone involved.

A Best Possible Medication History is the most accurate and complete list of all medications a patient is taking, including prescription drugs, over-the-counter medications, and supplements. It is obtained by cross-referencing information from multiple sources, not just the patient's memory.

All medications should be included, such as prescription medications, over-the-counter drugs, herbal products, vitamins, and other supplements. Inaccurate or incomplete information on any of these can lead to potential drug interactions or unintended outcomes.

If a discrepancy is identified, the prescriber or a designated expert (often a pharmacist) must investigate the reason for the difference and make a clinical decision. This may involve adjusting the dose, discontinuing a medication, or correcting an omission.

Patients can help by keeping and carrying an up-to-date, comprehensive list of their medications with them to every healthcare encounter. They should also inform their providers of any changes, adherence issues, or any herbal or OTC medications they are taking.

During admission, the focus is on gathering a thorough BPMH to create an accurate baseline for inpatient care. At discharge, the focus is on updating the medication list to reflect hospital changes and ensuring the patient understands the final plan for home.

While EHRs can streamline the process and provide valuable data, they are not a substitute for a thorough medication interview and manual verification. Technology can have limitations, such as lack of interoperability between different systems, so relying solely on it is not advisable.