Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation

Chapter 7. High-Risk Situations for Medication Reconciliation

This chapter addresses the various challenges and barriers to addressing medication reconciliation as well as recommendations to handle these. Patients with limited health literacy and/or cognitive impairment are high risk for medication reconciliation errors that can result in an ADE if this risk is not identified by the clinician.

Health Literacy

The definition of health literacy is neither simple nor universally well understood. No matter how health literacy is defined, patients with limited health literacy have an increased likelihood of experiencing difficulty processing information about health and health care encounters. Within the realm of medication reconciliation, patients with limited health literacy may have problems adhering to a medication regimen and may be unable to provide an accurate medication history. These individuals often do not understand prescription instructions and warning labels, and they may be at increased risk for medication errors and non-compliance. When these patients are discharged from the inpatient setting, instruction on changes to their prior medications or a new medication may require more targeted efforts from clinicians.

According to a national survey, over one-third of the adult population has limited health literacy, meaning that they have basic or below basic health literacy levels.11 Limited health literacy is associated with medication errors, increased health care costs, and inadequate knowledge of and care for chronic health conditions.12,13,14

Determining which patients have limited health literacy can be very difficult for health care providers. Some patients with limited health literacy may still have these characteristics:

  • Have completed high school or college.
  • Are well spoken.
  • Look over written health related materials and say they understand.
  • Hold white collar or health care jobs.
  • Function well when not under stress.

Experts recommend assuming that everyone may have some difficulty understanding health care information and suggest creating an environment where patients of all literacy levels can thrive. In the case of health literacy universal precautions, facilities should ensure that systems are in place to promote better understanding for all patients, not just those you think need extra assistance. Improving patient understanding is beneficial for the patient and health care provider. Research suggests that clear communication practices and removing literacy-related barriers will improve care for all patients regardless of their level of health literacy.15

Studies have shown that 40-80 percent of the medical information patients receive is forgotten immediately,16 and nearly half of the information retained is incorrect.17 One of the easiest ways to close the gap of communication between clinician and patient is to employ the "teach-back" method, also known as the "show-me" method or "closing the loop."18

"Teach-back" is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands. Patient understanding is confirmed when they explain it back to you. It can also help clinical staff members identify explanations and communication strategies that are most commonly understood by patients. Each facility should consider integrating this basic concept into their patient education requirements for medication teaching as well as other instructions to patient.15

The Cognitively Impaired Patient

Cognitive impairment may also pose challenges for medication reconciliation when obtaining medication histories from patients upon admission or providing medication education and counseling to patients at discharge. Screening for cognitive impairment can be time-consuming. If cognitive impairment is a concern, a simple screening test is the Mini-Cog. As opposed to the Mini-Mental State Examination (MMSE,, which takes roughly 10 minutes to administer, the Mini-Cog can be administered in well under 5 minutes. The Mini-Cog uses a three-item recall test for memory and a simply scored clock-drawing test. The test has been shown to have good predictive value in diverse populations, both in relation to the MMSE and more thorough cognitive exams.19,20

A patient is often asked to read something in their doctor's office. They may be asked to fill out a form or may be given written material on how to manage their disease. A patient's reading abilities are often below the readability of this material. In addition, patients who are ill can sometimes find it hard to answer complex questions accurately. Medical practices that are conscientious about developing and using written materials that are easier to read may increase the chance that their patients will use health information correctly, thereby saving staff time and improving patient outcomes.15

Patients who say they "often" or "always" have someone help them to read hospital materials, or who are "a little bit" or "not at all" confident filling out forms, are more likely to have reading problems. These patients should be given special attention during the medication reconciliation process, such as during patient interviews to obtain medication histories upon admission and at discharge for medication education and counseling.21,22,23,24

Ideally, staff should ask patients these two screening questions when they establish care, and all providers should be mindful of patient responses during encounters. However, screening tools will never be able to perfectly predict or measure patient characteristics and behavior. Thus, it may be better to assume that all patients experience some degree of difficulty in understanding health information, and we should adopt the perspective of "universal precautions" when interacting with patients. These methods include the use of plain language, communication tools (e.g., multimedia), and "teach-back" (having an individual repeat back instructions to assess comprehension) with all patients.

External Transfer Cases

An external transfer patient is a patient who is transferred from a hospital outside of the hospital's own system. Such transfers may occur based on patient or provider request, specialty services required, or additional acute care needs.

External transfer patients have additional complexity in regards to medication reconciliation because three sources of information require review and reconciliation:

  • Patient's list of home medications prior to their hospitalization.
  • Medications that are being administered to the patient at the outside hospital prior to transfer.
  • Medications ordered at the receiving hospital.

If the organization receives transfers from other hospitals, you should ensure a process is in place to address these reconciliation needs. Adequate communication and handoffs from the sending facility are critical to ensure all medication therapies are addressed and reconciled during the assessment and development of the patient's care plan at the receiving organization.

Page last reviewed August 2012
Page originally created August 2012
Internet Citation: Chapter 7. High-Risk Situations for Medication Reconciliation. Content last reviewed August 2012. Agency for Healthcare Research and Quality, Rockville, MD.
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