This site is intended for health professionals only

24 hours medicines reconciliation in hospital

Why the UK government recommendation for patients admitted to hospital to receive medicines reconciliation from a pharmacist is poorly evidence-based, both with respect to the 24-hour requirement and the need to see all patients is discussed


David Wright BPharm (Hons) PGCHE PhD
Professor of Pharmacy Practice, University of East Anglia, UK
Brit Cadman MPharmS MFRPSII
Consultant Pharmacist and Principal Investigator, Cambridge University Hospital, UK

Why the UK government recommendation for patients admitted to hospital to receive medicines reconciliation from a pharmacist is poorly evidence-based, both with respect to the 24-hour requirement and the need to see all patients is discussed


David Wright BPharm (Hons) PGCHE PhD
Professor of Pharmacy Practice, University of East Anglia, UK
Brit Cadman MPharmS MFRPSII
Consultant Pharmacist and Principal Investigator, Cambridge University Hospital, UK


Medical information systems within different care settings are unable to communicate with each other. This has resulted in the need for medicines reconciliation (MR) when patients are admitted to and discharged from hospital. MR is defined by the World Health Organization as ‘the formal process in which healthcare professionals partner with patients to ensure accurate and complete medication information transfer at the interfaces of care’1 MR has become a central responsibility for pharmacy departments in secondary care settings2 and increasingly in primary care.3

Reliance on a single healthcare professional to take a full medication history at the same time point as providing a physical examination and developing a preliminary diagnosis has been found to result in unintentional errors rates of between 30% and 70% relating to hospital prescriptions on admission.4–9 The omission of medicines prescribed in primary care, prescription of incorrect dosages and addition of medicines which have not been previously prescribed have all been shown to occur. This is known to contribute to patient morbidity and mortality and increase the length of hospital stay.10–14

In the UK in 2007, patient safety guidance issued by the National Patient Safety Agency (NPSA) and the National Institute for Health and Care Excellence (NICE) recommended that policies for MR should be implemented in hospitals for all adult patient admissions. Part of this recommendation is that pharmacy should be involved in the MR process within 24 hours of admission.15 While the evidence for the recommendation to use pharmacists in the process has built over time,2,4,16–19 the rationale for it to occur within 24 hours is not underpinned in the same manner.

While the length of stay within secondary care continues to reduce to a current overall average of less than two days in the UK,20 it would seem appropriate for MR to occur within 24 hours. Delaying MR beyond 24 hours in most acute admissions may reduce the chances of it occurring at all during a patients hospital stay. Furthermore, the longer the delay, the greater the likelihood of patients being harmed due to any prescribing errors. It should however, also be considered that the majority of those patients, who are admitted and discharged in less than two days, are more likely to use their own medicines during admission and less likely to experience significant changes in long term medication. They are also less likely to be prescribed large numbers of medicines and less likely to require pharmacist intervention.21

The 24-hour requirement creates difficulties for pharmacy departments that have traditionally worked from Monday to Friday with normal office hours, only providing cover to address supply problems outside of these times. Patients admitted between Friday evening and Sunday lunchtime have traditionally been unlikely to receive MR within the required timeframe. The introduction of the target therefore requires additional resources or their reallocation and therefore loss from another element of service delivery.

MR effectiveness
A systematic review of medicines reconciliation practices by Mueller et al in 201218 found only a limited number of good quality studies at the time. They however all showed that the process reduced medicines discrepancies and most demonstrated a reduction in potential adverse drug events. The evidence at that time to support a reduction in post-discharge hospital utilisation was however at that time limited. The study reported variations in the model of MR delivery within different studies, which reported using pharmacists, trainee pharmacists or pharmacy technicians.

The researchers, however, suggested that those services, which were limited to older people, delivered on admission, during and at discharge with direct communication with physicians and a follow up telephone call were likely to be most effective. Conversely, those studies, which showed limited effect, used pharmacists only during admission or discharge. The time of service delivery in relation to admission was not stated.

A more recent systematic review of pharmacist led MR services by Mekonnen et al in 20162 showed that such services provided significant reductions in adverse drug event related readmissions, emergency department visits and hospital readmissions. The majority of evidence however emanated from the USA with only a small number from European and other countries (Sweden (n=3), Ireland (n=2) and Australia (n=1)). They were mainly either non-randomised controlled trials or before and after studies and consisted of interventions purely on admission, on discharge or at both points. Whilst the authors did not differentiate between single and multiple transition interventions, re-analysis of the same data showed that multiple transition interventions still had a significant effect.22

A large number of the trials included within the review2 consisted of additional elements to the intervention such as medication review, patient education, discharge plan and follow up telephone call. Medication reviews themselves performed by hospital pharmacists, are believed to reduce hospital readmissions17 and therefore the inclusion of trials makes it difficult to determine the exact cause of the effect.

The majority of studies included within the Mekonnen review2 were focussed on high risk patients, that is, those prescribed a large number of medicines, prescribed medicines which are deemed to be high risk or have conditions for which effective control and management is highly dependent on medicines, for example, heart failure. Researchers have again separately shown that hospital pharmacist inpatient services for patients with heart failure are likely to reduce the likelihood of unplanned readmission.23

Consequently, due to the limited quality of the data, the variations in service models and the focus on certain types of patient, the authors state that the results from their review should be viewed with some caution.

MR cost-effectiveness
Interestingly, while the UK government mandates that MR within 24 hours for all hospital admissions by a hospital pharmacist is required, there is no evidence to suggest that the intervention is a cost-effective use of resources.24

In the UK, the government will only recommend interventions where the attainment of one additional year of perfect quality of life costs less than £20,000, increasing to £30,000 in certain circumstances.25 A model built in 2008 to estimate the likely cost-effectiveness of preventing medication error at hospital admission using MR suggested that a pharmacist-based intervention is likely to be cost-effective. The model was, however, based solely on USA error data and made assumptions concerning the severity of errors prevented and their consequences, which are unlikely to provide an accurate reflection of the effectiveness of the intervention.26


As a model that is not underpinned by a randomised controlled trial, in accepting the finding, the reader has to accept that the assumptions underpinning the model would translate into their health system and that the costs realised would be the same in their country. With the significant differences seen between the organisation of USA and European health systems, it is perhaps not appropriate to directly translate these findings.

The time taken for the provision of MR at both admission and discharge is 45 minutes on average and therefore achieving this in 24 hours for all hospital admissions represents a significant amount of resources.27 A recently reported feasibility study where patients were randomised to either MR at both transition points or usual care that may or may not have included MR, found that usual MR took on average 15 minutes per patient and was far less likely to reduce medicine discrepancies.28 The 15 minutes per patient in the usual care group is likely to be due to the demand for all patients to be seen with limited or no additional resources provided to meet this.

The difference between the effectiveness seen within research studies and that seen in reality has been previously reported.29 Within a trial, the intervention is delivered to protocol, is novel, and there is frequently greater buy-in from all stakeholders who want to demonstrate a positive effect. This effect may erode with time, when different practitioners deliver it and if the amount of resources used to deliver the intervention are reduced.

It is clear that the UK government recommendation for patients admitted to hospital to receive MR from a pharmacist is poorly evidence-based both with respect to the 24-hour requirement and the need to see all patients. The data support the provision of MR in high-risk patients and suggest that MR at both transition points may be preferable to provision at one transition point. Furthermore, an additional phone call post-discharge may be warranted.

Perhaps of greater concern is the limited amount of high-quality evidence for the effectiveness of MR provided by hospital pharmacists within European hospitals. With heterogeneity in MR delivery with respect to the service provider and location of the service within the admission cycle, differences in service recipients, and the addition of other elements alongside MR that are known to be effective in themselves, it is also currently not possible to describe the best model of MR delivery. As MR delivery by pharmacists becomes ubiquitous and hospital pharmacy services become more sophisticated, the ability to perform high quality studies with clean well-defined interventions and true control arms diminishes.

When evidence is pooled regarding very different MR services from a variety of healthcare systems, significant reductions in unnecessary post-hospitalisation resource utilisation are seen. The question, however, is not whether MR is required or works but whether the amount of resource that is required to effectively deliver the intervention justifies the outcome. Within all resource limited healthcare systems, it is important that services are provided to those with greatest need and not ubiquitously to all patients if this is likely to significantly increase costs without significantly improving outcomes.

While it would seem to be common sense to strive towards providing MR within 24 hours to all patients to limit the amount of time that any patient is exposed to potential drug errors, setting of the target itself may result in unintended consequences. As with many government targets for healthcare providers, these are frequently chosen because they are easy to measure objectively, not because they are the most appropriate patient-oriented outcome.

Targets of this nature can result in inappropriate local allocation of resources because service providers tasked to meet them may choose to focus the limited resources on all newly admitted patients which may include low-risk patients. If resources are focussed in this manner, then complex patients who are most likely to benefit may be missed or only receive limited amount of time from the pharmacist who is more focussed on seeing everyone and therefore must ration time accordingly. The effect of a target for 24 hours MR by hospital pharmacists for all patients may therefore be detrimental rather than helpful.

The current state of MR research in European hospitals is such that high quality, multi-site, randomised controlled trials are warranted and that cost-effectiveness of different models of delivery should be determined.

As a complex intervention, that is, the inclusion of a wide range of elements within its delivery, then effective process evaluation would be required to tease out which elements of the service are effective. If MR is shown to be cost-effective then the same amount of resources used within the trial need to be available for service roll out. Introduction of simple non-patient focussed targets to ensure that the service is delivered may however be counterproductive and therefore need to be carefully considered before introduction.


Key points  

  • The UK government requires all patients admitted to hospital to receive medicines reconciliation within 24 hours.
  • There is robust evidence for medicines reconciliation in patients either prescribed large numbers of medications or within certain chronic diseases.
  • Whilst it is understandable to expect medicines reconciliation to occur as close to admission as possible, there is no evidence to support a 24 hour deadline.
  • Recent research suggests that setting such a target without providing additional resources may result in less time being available than is required to deliver effective medicines or with certain disease.
  • Pharmacist services should be focussed on those patients who are most likely to benefit and not reconfigured to meet non-evidence-based targets unless sufficient resources are provided to support this.



  1. World Health Organization. High 5s Fact Sheet: The High 5s Assuring Medication Accuracy at Transitions of Care: Medicines Reconciliation Standard Operating Procedure. (accessed April 2017)
  2. Mekonnen AB et al. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ open 2016;6(2):e010003.
  3. Nazar H et al. New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation. BMJ open 2016;6(10);e012532.
  4. Campbell F et al. A systematic review of the effectiveness and cost effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission. The University of Sheffield SoHaRRS/National Institute for Health and Clinical Excellence 2009. SystematicReview.pdf (accessed April 2017).
  5. Dornan T et al. Final report. An in-depth investigation into causes of prescribing errrors by foundation trainees in relation to their medical education. EQUIP Study. General Medical Council; 2009. (accessed April 2017).
  6. Gray E et al. Prescription errors in patients on an acute medical assessment unit. R Coll Phys Edinb 2007:37:305–8.
  7. McLeod SE, Lum E, Mitchell C. Value of medication reconciliation in reducing medication errors on admission to hospital. J Pharm Pract Res 2008;38(3):196–9.
  8. Coleman E et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 2005;165(16):1842–7.
  9. Cornish P et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165(4):424–9.
  10. Pippins JR et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med 2008;23(9):1414–22.
  11. The Audit Commission. A spoonful of sugar: Medicines management in NHS Hospitals. London. 2001. (accessed April 2017).
  12. Dean B et al. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care 2002;11(4):340–4.
  13. Department of Health. Management of medicines. A resource to support implementation of the wider aspects of medicines management for the National Service Frameworks for Diabetes, Renal Services and Long-term Conditions. 2004.
  14. Karnon J et al. Modelling the expected net benefits of interventions to reduce the burden of medication errors. J Health Serv Res Policy 2008;13(2):85–91.
  15. National Institute for Health and Care Excellence. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. PSG1. NICE; 2007. (accessed April 2017).
  16. Kwan JL et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158(5 Pt 2):397–403.
  17. Renaudin P et al. Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis. Br J Clin Pharmacol 2016;82(6):1660–73.
  18. Mueller SK et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med 2012;172(14):1057–69.
  19. Mekonnen AB et al. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis. J Clin Pharm Ther 2016;41(2):128–44.
  20. Health and Social Care Information Centre. Hospital Episode Statistics: Admitted Patient Care, England 2014–15. 2015.
  21. Suggett E, Marriott J. Risk factors associated with the requirement for pharmaceutical intervention in the hospital setting: A systematic review of the literature. Drugs Real World Outcomes 2016;3(3):241–63.
  22. Grimes TC et al. Comment on: pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis. J Clin Pharm Ther 2016;41(6):739–40.
  23. Thomas R et al. Pharmacist-led interventions to reduce unplanned admissions for older people: a systematic review and meta-analysis of randomised controlled trials. Age Ageing 2014;43(2):174–87.
  24. National Institute for Health and Care Excellence. Guide to the methods of technology appraisal 2013. PMG9. (accessed April 2017).
  25. Hammad EA et al. Pharmacy led medicine reconciliation at hospital: a systematic review of effects and costs. Res Social Adm Pharm 2017;13(2):300–12.
  26. Karnon J et al. Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation). J Eval Clin Pract 2009;15(2):299–306.
  27. Meguerditchian AN et al. Medication reconciliation at admission and discharge: a time and motion study. BMC Health Services Res 2013;13(1):1–11.
  28. Cadman B et al. Pharmacist provided medicines reconciliation within 24 hours of admission and on discharge: a randomised controlled pilot study BMJ open 2017;7(3):e013647.
  29. Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf 2016 25(9);726–30.

Be in the know
Subscribe to Hospital Pharmacy Europe newsletter and magazine