I still remember one of my first nights on service as a new hospitalist nearly 14 years ago. A frail elderly man had just arrived from the emergency department with congestive heart failure. His daughter sat at the bedside, clutching a plastic grocery bag filled with pill bottles—half empty, half relabeled, some prescribed years ago. As I sifted through them, I realized I had no idea which medications he was taking. The daughter didn’t either. “Mom used to handle all that,” she said quietly.
That night stayed with me. It was my first true lesson in medication reconciliation—not as a regulatory checkbox, but as a detective story that determines whether a patient leaves the hospital safer than they arrived.
The Daily Struggle Behind the List
Hospitalists know the ritual well: open the chart, find the “med rec” section, and hope the list you see is accurate.
Patients forget doses, outpatient records don’t sync, and facility medication lists may be weeks out of date. Pharmacy technicians and nurses often do the heavy lifting—calling retail pharmacies, reviewing bottles, and clarifying doses—but the final responsibility still lands with us.
Even with that support, the process is far from perfect. The handoffs between outpatient, inpatient, and post-acute settings remain some of the leakiest points in our system. When reconciliation goes wrong, the results can be devastating—a missed anti-epileptic medication here, a duplicate sedative there—and suddenly a preventable readmission becomes a case for root-cause analysis.
When Teamwork Turns the Tide
I’ve learned the best reconciliation is a team sport.
Some of the most successful programs I’ve seen don’t rely solely on the admitting physician. Pharmacists and pharmacy technicians start the process—verifying medications, contacting pharmacies, and reviewing discrepancies— while hospitalists review, clarify intent, and confirm before orders are finalized.
One of our partner hospitals piloted a tele-reconciliation model: remote pharmacists connected via secure video, reviewed medication histories, and even counseled patients before discharge. It sounded futuristic—until we saw the results. Admission medication reviews were completed far more consistently, and discharge reconciliation and education became remarkably efficient, with patients feeling better supported and more confident in their medication plans. Even more importantly, any potential discrepancies identified at discharge were immediately flagged to the attending physician by the telepharmacist, ensuring real-time clarification and an extra layer of safety around medication changes.
The takeaway was clear: reconciliation works best when it’s shared, structured, and supported.
How Technology (Almost) Helps
Electronic health records (EHRs) and automation have made parts of this easier, but not effortless.
The reconciliation module in most systems highlights discrepancies and pulls pharmacy fill data. That’s helpful—but only if the upstream data is clean. I’ve had plenty of “reconciled” lists that were anything but accurate because an outside source hadn’t updated the record.
Recently, we’ve begun experimenting with AI-assisted reconciliation tools that can read free-text notes and flag inconsistencies across sources. Early results are promising—faster, fewer errors, and less time manually entering drug names. But even the smartest algorithm can’t replace the conversation with a patient who looks you in the eye and says, “Actually, I stopped taking that months ago.”
The Human Side of Safety
The most transformative moments come when patients—and their caregivers—become part of the process.
I’ve had families who keep a beautifully typed spreadsheet of every dose, and others who scribble notes on napkins. Either way, they want to be heard. When I slow down, use plain language, and ask them to repeat back the new plan—the teach-back method—the difference is tangible. They leave more confident, and I leave less anxious about the 48-hour callback from a confused relative.
Medication reconciliation isn’t just data hygiene; it’s relationship repair. It’s a conversation about trust, understanding, and shared responsibility.
Building One Source of Truth
One of the most overlooked steps in medication reconciliation is ensuring that the discharge medication list and the discharge summary speak the same language. Too often, they live in separate parts of the EHR, leaving future clinicians uncertain about which medications were new, stopped, changed, or continued.
When the final medication list is embedded directly within the physician’s discharge summary— clearly identifying each of those categories—it becomes a single, reliable source of truth. It saves time, reduces confusion, and turns the summary from a regulatory document into what it should be: a clear bridge between hospital and home.
Measuring What Matters
Every hospital loves dashboards, and reconciliation is no exception. We track the percentage of admissions with completed med recs, the number of discrepancies, and 30-day readmissions tied to medication errors.
But the metrics that matter most to me aren’t always in spreadsheets. They’re in the moments when a nurse messages me, “Thanks for clarifying that insulin dose,” or when a patient says, “Now I finally understand what all these pills are for.”
That’s the real ROI, not just “return on investment,” but return on intention.
Closing the Loop—and the List
After years of practicing hospital medicine, I’ve learned that reconciliation works best when systems protect time and give hospitalists the space to do it right. When census pressures ease, when pharmacists and techs are empowered, when digital tools and human judgment meet halfway, that’s when safety stops being theoretical and becomes personal.
Every now and then, I remember that first night—the daughter, the grocery bag, the uncertain pills— and I’m reminded that reconciliation is one of the quietest, most powerful acts of patient safety we perform.
If we can make medication reconciliation work for us, it will work for our patients — and that’s the list that really matters.
Dr. Patel
Dr. Patel is chair of the inpatient clinical informatics council at Ballad Health in Johnson City, Tenn. He recently relocated to Sacramento, Calif., where he practices hospital medicine part-time for Kaiser Permanente and Sutter Health. He also chairs SHM’s Health Information Technology Special Interest Group.