Academic Day Seminar #8: Medication Reconciliation

I haven’t had the opportunity to use the medication reconciliation form yet, but have incorporated getting the BPMHs into my patient interviews. Having the BPMH allows me to identify any discrepancies between the medications in hospital and medications PTA. In SMH, pharmacists are allowed to order medications that ensure continuity of care. However, on the med rec form, only prescribers are allowed to fill in the reconciliation column (medication orders) of the form. In my future rotations, when performing medication reconciliations, I will keep the following in mind:

  • Med Rec requires medication history (from patient, caregiver, GP, community pharmacists, etc) AND Pharmanet
  • 3 step process: Collection and Verification (= BPMH and chart review) and then Reconciliation
  • Ask questions about drugs not listed in P’net: antiretrovirals, non-rx, vitamins, samples, study drugs, recreational drugs, herbal/traditional remedies, medications from outside of province or internet
  • Ask questions about unique dosage forms: eye drops, inhalers, injections, patches, sprays
  • Use open-ended questions: “Tell me how you take this medication?”
    • This might be hard for patients to answer, especially if they rely on a blister pack. But, I think it is definitely a good question to ask and to also have the P’net on hand to help guide the patient
  • Assess adherence PTA: fill dates, quantities listed in P’net and inquire about discrepancies
  • Verify accuracy with TWO sources.
  • Discuss with medical team and document
  • Transfers: when transferring between different levels of care, from hospital to hospital, post-op
  • Watch out for: duplication between orders on MRO and between MRO and PPOs
  • Role of pharmacists in ensuring quality med recs – an empty med rec form with a signature by the prescriber is like a blank cheque (as other well-meaning HCPs can fill it out under their name)

C3.2 R5: Reconcile a patient’s medications on ADMISSION

With the help and guidance of my preceptor, I completed a medication reconciliation on admission. Generally, medication reconciliation is done in Emerg. However, this patient had a MVA and was transferred from another hospital directly to our ward with the goal of repatriation.

In Saanich, patient was taking:

  • Citalopram 10mg once daily, as per P’net
  • Gliclazide 60mg MR twice daily with food, as per P’net
  • Metformin 1000mg BID with food, as per P’net
  • Linagliptin 2.5mg BID with food, as per P’net
  • Pantoprazole Mg 40mg once daily 1/2 hour before food, as per P’net
  • Timolol 0.5% 1 drop in both eyes BID (different from P’net)
  • Zopiclone 5mg HS PRN (not on P’net)

On P’net but not on transfer:

  • Ferrous fumarate 300mg capsule twice a week (Mon and Thurs)

Medication Reconciliation:

Patient was able to confirm that he was taking all his oral medications as per P’net, as well as, strength and regimen. For non-prescriptions, he was taking calcium and vitamin D, vitamin B12 and a multi-vitamin for over 50 years old. No samples. He uses blister packs. However, he had difficulty in identifying the eye drops and their regimens. I had to look at MediTech –> EMR –> Patient’s Summary and click next of kin. I called the daughter who was able to bring in the eye drops and his old blister pack. Along with my preceptor, we confirmed the following:

  • Travoprost (Travatan Z) 0.004% Instil 1 drop in right eye HS
  • Brimonidine Tartrate (Alphagan P) 0.15% Instil 1 drop in right eye BID
  • Brinzolamide (Azopt) 1% Instil 1 drop in right eye BID
  • Timolol (Timoptic-Xe) 0.5% Sol-gel Instil 1 drop in left eye QAM (as per pt – P’net said both eyes –> some confusion but patient later thought likely both eyes)
  • Prednisolone 1% Instil 1 drop in left eye TID (but pt usually does it twice)
  • NOT taking fluorometholone 0.1% drops
  • Medications taken in blister pack was as confirmed with patient previously


  1. Decrease metformin to 500mg BID d/t risk of lactic acidosis while having chronic renal dysfunction (eGFR ~low 40s)
  2. Change Timolol 0.5% to 1 drop in both eyes QAM
  3. Start Prednisolone 1% 1 drop in left eye TID
  4. Start Travoprost 0.004% 1 drop in right eye HS
  5. Start Brimonidine Tartrate 0.15% 1 drop in right eye BID
  6. Start Brinzolamide 1% 1 drop in right eye BID


  • I should have had a closer look at the Pharmanet to clarify any differences between P’net and what the patient was telling me. I noticed later on that timolol was written for both eyes QAM on the P’net and went back to re-clarify with the patient. There was some confusion but both daughter and him decided it was best to follow the P’net and patient seemed to think that he might have been using it for both eyes. The unit clerk and pharmacy staff probably didn’t appreciate the extra order I wrote only one hour later.
  • My preceptor helped confirm the eye-drops with the patient in a very efficient way. He showed the eye drops to him as he asked how many drops and how many times he was taking it. He re-confirmed and summarized the regimens at the end. For my future medication reconciliations, I will read out the final list of medications at the end to the patient and confirm its accuracy.
  • When asking for non-prescription medications, I forgot to list out non-prescription formulations – e.g. creams, ointments, etc. Some people may not consider topical medications a medication, so it would be good to list them out for the patient.