Enhancing the continuity of medication therapy with the standard operating protocol

Written by Nigmatkulova M.D., Kleymenova E.B., Yashina L.P., Sychev D.A.

  UDK: 615.035:615.03/.7 | DOI: 10.17238/PmJ1609-1175.2019.1.13–17  Pages: 13–17 | Full text PDF | Open PDF 


The paper presents a review of publications on the problem of medication therapy continuity during patient’s transfer between levels of healthcare and an impact of its failure on adverse drug events rate. One of the most efficient and costeffective approach of improving drug therapy continuity is standardization of the medication reconciliation procedure which is recommended by the World Health Organization and implemented in many countries. The evidence of the medication reconciliation efficiency in improving the patient safety, reducing the risk of prescribing errors, preventable adverse drug events and financial burden on health care is discussed.

Links to authors:

M.D. Nigmatkulova1, 2, E.B. Kleymenova1–3, L.P. Yashina1, 3, D.A. Sychev2
1 General Medical Center of the Bank of Russia (66 Sevastopolsky Ave. Moscow 117593 Russian Federation),
2 Russian Medical Academy of Continuous Professional Education (12/12 Polikarpova St. Moscow 125284 Russian Federation),
3 Federal Research Center “Computer Science and Control” (44/2 Vavilova St. Moscow 119333 Russian Federation)

1. Al-Hashar A., Al-Zakwani I., Eriksson T. [et al.]. Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use // Int. J. Clin. Pharm. 2018. Vol. 40, No. 5. P. 1154–1164.
2. Australian Commission on Safety and Quality in Healthcare. Medication reconciliation. URL: http://www.safetyandquality. gov.au/our-work/medication-safety/medication-reconciliation (date of access: 15.01.2019).
3. Boockvar K.S., Blum S., Kugler A. [et al.]. Effect of admission medication reconciliation on adverse drug events from admission medication changes // Arch. Intern. Med. 2011. Vol. 171, No. 9. P. 860–861.
4. Canadian Council on Health Services Accreditation. Required Organizational Practices (ROP) Handbook 2017. Version 2. URL: https://accreditation.ca/required-organizational-practices/ (date of access: 23.01.2019).
5. Cano F.G., Rozenfeld S. Adverse drug events in hospitals: a systematic review // Cad. Saúde Pública. 2009. Vol. 25, Suppl. 3. P. S360–S372.
6. Cheema E., Alhomoud F.K., Kinsara A. [et al.]. The impact of pharmacists- led medicines reconciliation on healthcare outcomes in secondary care: A systematic review and meta-analysis of randomized controlled trials // PLoS ONE. 2018. Vol. 13, No. 3. P. e0193510.
7. Cornish P.L., Knowles S.R., Marchesano R. [et al.]. Unintended medication discrepancies at the time of hospital admission // Arch Intern Med. 2005. Vol. 165, No. 4. P. 424–429.
8. De Boer M., Boeker E.B., Ramrattan M.A. [et al.]. Adverse drug events in surgical patients: an observational multicentre study // Int. J. Clin. Pharm. 2013. Vol. 35. P. 744–752.
9. De Vries E.N., Ramrattan M.A., Smorenburg S.M. [et al.]. The incidence and nature of in-hospital adverse events: a systematic review // Qual. Saf. Health Care. 2008. Vol. 17, No. 3. P. 216–223.
10. Dobranzkil S., Hammond I., Khan G., Holdsworth H. The nature of hospital prescribing errors // Br. J. Clin. Govern. 2002. Vol. 7. P. 187–193.
11. Eggink R.N., Lenderink A.W., Widdershoven J.W. [et al.]. The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure // Pharm. World Sci. 2010. Vol. 32. P. 759–766.
12. Gillespie U., Alassaad A., Henrohn D. [et al.]. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial // Arch. Intern. Med. 2009. Vol. 169. P. 894–900.
13. Hron J.D., Manzi S., Dionne R. [et al.]. Electronic medication reconciliation and medication errors // Int. J. Qual. Health Care. 2015. Vol. 27, No. 4. P. 314–319.
14. Hug B.L., Witkowski D.J., Sox C.M. [et al.]. Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention // J. Gen. Intern. Med. 2010. Vol. 25. P. 31–38.
15. Institute for Healthcare Improvement. Medication Reconciliation Review. IHI, 2004. 5 р. URL: http://www.ihi.org/resources/ Pages/Tools/MedicationReconciliationReview.aspx (date of access:
16. Joint Commission on Accreditation of Healthcare Organizations. Hospital: 2019 National Patient Safety Goals URL: https://www. jointcommission.org/hap_2017_npsgs/ (date of access: 23.01.2019).
17. Joint Commission on Accreditation of Healthcare Organizations. Using medication reconciliation to prevent errors. // Jt Comm. J. Qual. Patient Saf. 2006. Vol. 32, No. 4. P. 230–232.
18. Kaushal R., Bates D.W., Abramson E.L [et al.]. Unit-based clinical pharmacists› prevention of serious medication errors in pediatric inpatients // Am. J. Health Syst. Pharm. 2008. Vol. 65. P. 1254–1260.
19. Koehler B.E., Richter K.M., Youngblood L. [et al.]. Reduction of 30-day post-discharge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle // J. Hosp. Med. 2009. Vol. 4, No. 4. P. 211–218.
20. Kucukarslan S.N., Peters M., Mlynarek M., Nafziger D.A. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units // Arch. Intern. Med. 2003. Vol. 163. P. 2014–2018.
21. Kwan Y., Fernandes O.A., Nagge J.J. [et al.]. Pharmacist medication assessments in a surgical preadmission clinic // Arch. Intern. Med. 2007. Vol. 167. P. 1034–1040.
22. Laatikainen O., Miettunen J., Sneck S. [et al.]. The prevalence of medication-related adverse events in inpatients – a systematic review and meta-analysis // Eur. J. Clin. Pharmacol. 2017. Vol. 73, No. 12. P. 1539–1549.
23. Leape L.L., Cullen D.J., Clapp M.D. [et al.]. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit // JAMA. 1999. Vol. 282. P. 267–270.
24. Lisby M., Thomsen A., Nielsen L.P. [et al.]. The effect of systematic medication review in elderly patients admitted to an acute ward of internal medicine // Basic Clin. Pharmacol. Toxicol. 2010. Vol. 106, No. 5. P. 422–427.
25. McNab D., Bowie P., Ross A. [et al.]. Systematic review and meta-analysis of the effectiveness of pharmacist led medication reconciliation in the community after hospital discharge // BMJ Qual. Saf. 2018. Vol. 27. P. 308–320.
26. Mekonnen A.B., Abebe T.B., McLachlan A.J., Brien J.E. Impact of electronic medication reconciliation interventions on medication discrepancies at hospital transitions: a systematic review and metaanalysis // BMC Med. Inform. Decis. Making. 2016. Vol. 16. P. 112.
27. Mekonnen A.B., McLachlan A.J., Brien J.A. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis // BMJ Open. 2016. Vol. 6, No. 2. P. e010003.
28. Mekonnen A.B., McLachlan A.J., Brien J.A. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis // J. Clin. Pharmacy Therap. 2016. Vol. 41, No. 2. Р. 128–144.
29. Murphy E.M., Oxencis C.J., Klauck J.A. [et al.]. Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge // Am. J. Health Syst. Pharm. 2009. Vol. 66, No. 23. P. 2126–2131.
30. National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. URL: https://www.nice.org.uk/guidance/ ng5/chapter/1-Recommendations#medicines-reconciliation (date of access: 23.01.2019).
31. NCC MERP Index for Categorizing Medication Errors. – 1996, Revised: February 20, 2001. URL: https://www.nccmerp.org/sites/ default/files/indexColor2001-06-12.pdf (date of access: 15.01.2019).
32. Poudel D.R., Acharya P., Ghimire S. [et al.]. Burden of hospitalizations related to adverse drug events in the USA:a retrospective analysis from large inpatient database // Pharmacoepidemiol. Drug Saf. 2017. Vol. 26, No. 6. P. 635–641.
33. Pronovost P., Weast B., Schwarz M. [et al.]. Medication reconciliation: a practical tool to reduce the risk of medication errors // J. Crit. Care. 2003. Vol. 18. P. 201–205.
34. Redmond P., Grimes T.C., McDonnell R. [et al.]. Impact of medication reconciliation for improving transitions of care // Cochrane Database of Systematic Reviews. 2018. Iss. 8, Art. No. CD010791.
35. Rodriguez V.B., Delgado S.E., Iglesias P.I., Bermejo V.T. Prevalence and risk factors for medication reconciliation errors during hospital admission in elderly patients // Int. J. Clin. Pharm. 2016. Vol. 38, No. 5. P. 1164–1171.
36. Santell J.P. Reconciliation failures lead to medication errors // Jt Comm. J. Qual. Patient Saf. 2006. Vol. 32, No. 4. P. 225–229.
37. Schnipper J.L., Hamann C., Ndumele C.D. [et al.]. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events // Arch. Intern. Med. 2009. Vol. 169, No. 8. P. 771–780.
38. Schnipper J.L., Kirwin J.L., Cotugno M.C. [et al.]. Role of pharmacist counseling in preventing adverse drug events after hospitalization // Arch. Intern. Med. 2006. Vol. 166, No. 5. P. 565–571.
39. Schwendimann R., Blatter C., Dhaini S. [et al.]. The occurrence, types, consequences and preventability of in-hospital adverse events – a scoping review // BMC Health Services Research. 2018. Vol.18. P. 521.
40. Society for Hospital Medicine. MARQUIS Implementation Manual. A guide for Medication Reconciliation Quality Improvement. SHM, 2014. 208 p.
41. Sullivan C., Gleason K.M., Rooney D. [et al.]. Medication reconciliation in the acute care setting: opportunity and challenge for nursing // J. Nurse Care Qual. 2005. Vol. 20, No. 2. P. 95–98.
42. Tam V.C., Knowles S.R., Cornish P.L. [et al.]. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review // CMAJ. 2005. Vol. 173. P. 510–515.
43. Walker P.C., Bernstein S.J., Jones J.N. [et al.]. Impact of a pharmacist-facilitated hospital discharge program: a quasiexperimental study // Arch. Intern. Med. 2009. Vol. 169, No. 21. P. 2003–2010.
44. WHO Collaborating Centre for Patient Safety. The High 5s Project – Standard Operating Protocol for Medication Reconciliation. Assuring Medication Accuracy at Transitions in Care. WHO, 2014. 36 p. URL: https://www.who.int/patientsafety/implementation/ solutions/high5s/h5s-sop.pdf (date of access: 23.01.2019).


Founded in 1997  |  Editions in a year: 4, Articles in one issue: 30 |  ISSN of print version: 1609-1175  |  Ind.: 18410 (Agency "Rospechat’")  |  Edition: 1000 c.