March 2021
Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals
​​Author Biographies


Amy Harper, PhD, RN, Patient Safety Authority
Amy Harper ( is an infection prevention analyst for the Patient Safety Authority. She has more than 25 years of combined microbiology/nursing experience, including roles in infection prevention, medical-surgical and critical care nursing, teaching, and virology research. She is board certified in medical-surgical nursing (CMSRN) and in infection control and epidemiology (CIC), and is a member of the Academy of Medical-Surgical Nurses (AMSN), The Society for Healthcare Epidemiology of America (SHEA), and the Association for Professionals in Infection Control and Epidemiology (APIC).

Elizabeth Kukielka, PharmD, MA, RPH, Patient Safety Authority
Elizabeth Kukielka is a patient safety analyst on the Data Science and Research team at the Patient Safety Authority. Before joining the PSA, she was a promotional medical writer for numerous publications, including Pharmacy Times and The American Journal of Managed Care. Kukielka also worked for a decade as a community pharmacist and pharmacy manager, with expertise in immunization delivery, diabetes management, medication therapy management, and pharmacy compounding.

Rebecca Jones, MBA, RN, Patient Safety Authority
Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.


Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. Serious events related to medication reconciliation were most common among patients 65 years or older (55.9%; 52 of 93). The majority of events (58.1%; 54 of 93) contributed to or resulted in temporary harm and required treatment or intervention. Permanent harm or death occurred as a result of 3.3% (3 of 93) of the events. Admission/triage was the most frequent transition of care associated with events (69.9%; 65 of 93). The most common stage of the medication reconciliation process at which failures most directly contributed to patient harm was order entry/transcription (41.9%; 39 of 93) and resulted most frequently in wrong dose (n=21) or dose omission (n=13). Most events were discovered after the patient had a change in condition (76.3%; 71 of 93), and patients most often required readmission, hospitalization, emergency care, intensive care, or transfer to a higher level of care (58.0%; 54 of 93). Among 128 medications identified across all events, neurologic or psychiatric medications were the most common (39.1%; 50 of 128), and anticonvulsants were the most common pharmacologic class among neurologic or psychiatric medications (42.0%; 21 of 50). Based on our findings, risk reduction strategies that may improve patient safety related to the medication reconciliation process include defined clinician roles for medication reconciliation, listing the indication for each medication prescribed, and for facilities to consider adding anticonvulsants to their processes for medications with a high risk for harm.


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