Original Study Medication Reconciliation in Continuum of Care Transitions: A Moving Target Liron Danay Sinvani MD a, *, Judith Beizer PharmD a, b , Meredith Akerman MS c , Renee Pekmezaris PhD a, c, d, e, *, Christian Nouryan MA a , Larry Lutsky PhD f , Charles Cal RN, MS, MBA f , Yosef Dlugacz PhD a, f , Kevin Masick PhD f , Gisele Wolf-Klein MD a, d, e a North Shore-LIJ Health System, New Hyde Park, NY b College of Pharmacy and Health Sciences, St. John’s University, Queens, NY c Feinstein Institute for Medical Research, Manhasset, NY d Hofstra North Shore-LIJ School of Medicine, Hempstead, NY e Albert Einstein College of Medicine, Bronx, NY f Krasnoff Quality Management Institute, New Hyde Park, NY Keywords: Medication reconciliation transition discrepancies abstract Objective: To study medication discrepancies in clinical transitions across a large health care system. Design: Randomized chart review of electronic medical records and paper chart medication reconcilia- tion lists across 3 transitions of care. Settings and participants: Subacute patient medication records were reviewed through 3 transition care points at a large health care system, including hospital admission to discharge (time I), hospital discharge to skilled nursing facility (SNF; time II) and SNF admission to discharge home or long term care (LTC; time III). Measurements: Medication discrepancies were identified and categorized by the principal investigator and a pharmacist. Discrepancies were defined as any unexplained documented change in the patients’ medication lists between sites and unintentional discrepancies were defined as any omission, duplica- tion, or failure to change back to original regimen when indicated. Results: We reviewed 1696 medications in the 132 transition records of 44 patients, identifying 1002 discrepancies. Average age was 71.4 years and 68% were female. Median hospital stay was 5.5 days and 14.5 SNF days. Total medications at hospital admission, hospital discharge, SNF admission, and SNF discharge were 284, 472, 555, and 392, respectively. Total medication discrepancies were 357 (time I), 315 (time II), and 330 (time III). All patients experienced discrepancies and 86% had at least 1 unintentional discrepancy. The average number of medications per patient increased at time I from 6.5 to 10.7 (P < .001), increased at time II from 10.7 to 12.6 (P <.0174), and decreased at time III from 12.6 to 8.9 (P <.001). Patients, on average, had 8.1, 7.2, and 7.6 medication discrepancies at times I, II, and III, respectively. Surgical patients had more discrepancies than medical at times I and III (8.94 vs 5.3, P < .019; 8.0 vs 5.8, P < .028). In the unintentional group, cardiovascular drugs represented the highest number of discrepancies (26%). Conclusion: This study is the first to follow medication changes throughout 3 transition care points in a large health care system and to demonstrate the widespread prevalence of medication discrepancies at all points. Our findings are consistent with previously published results, which all focused on single site transitions. Outcomes of the current reconciliation process need to be revisited to insure safe delivery of care to the complex geriatric patient as they transition through health care systems. Copyright Ó 2013 - American Medical Directors Association, Inc. Numerous studies show that medical errors and quality defi- ciencies commonly occur at times of transition. 1,2 Transitional care, during which a patient moves between different sites or levels of care, is a complex process fraught with challenges, particularly for the vulnerable geriatric population. 3,4 Moore et al demonstrated that nearly one-half of adult patients discharged from the hospital will have a medication error leading to discontinuity of care, with a significant increase in adverse drug events, rehospitalizations, and costs. 5e7 Astoundingly, Forster et al found that 75% of these transition errors are likely preventable. 6,7 Medication discrepancy is defined in the literature as an incom- patibility in a patient’s documented medication regimen including medication additions, omissions, therapeutic interchanges, dosing * Address correspondence to Renee Pekmezaris, PhD, North Shore-LIJ Health System, 175 Community Dr, Great Neck, NY 11021 or Liron Danay Sinvani, MD, North Shore-LIJ Health System, 300 Community Dr, Manhasset, NY 11030. E-mail addresses: rpekmeza@nshs.edu (R. Pekmezaris), ldanay@nshs.edu (L.D. Sinvani). JAMDA journal homepage: www.jamda.com 1525-8610/$ - see front matter Copyright Ó 2013 - American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2013.02.021 JAMDA 14 (2013) 668e672