Two hospitals within Vancouver Island Health Authority (VIHA), Royal Jubilee and Victoria General Hospital, are participating in a process called medication reconciliation during the patient admission process. This program has shown dramatic decreases in the occurrence of adverse drug events by reconciling a patient’s home medications upon admission to the hospital for surgery. The program has demonstrated a 96 per cent decrease in unintentional medication discrepancies from one per patient to 0.04 per patient.

In 2006, a multi-disciplinary medication reconciliation program was implemented for same-day admission patients, starting in the Pre-Admission Clinic (PAC) at the 450-bed Royal Jubilee hospital. The team consisted of clinical nurse leaders and educators, the chief of surgery, the clinical pharmacy manager and a medical reconciliation pharmacist. A home medication and reconciliation physician order form was developed which allowed a PAC pharmacist to compile a complete and accurate list of the patient’s home medications. This form was then signed by the surgeon, becoming part of the patient’s post-operative orders. The team also developed educational materials, including a video, now available on the hospital intranet.

Other benefits resulting from this program have been observed. Drug-related problems are detected by the PAC pharmacist and resolved prior to admission. The program also ensures that medications are ordered accurately and completely at the time admission, decreasing the amount of time spent by staff to clarify medication orders. Patients are receiving their medications faster and staff is more efficient, creating more time for quality patient care.

The program spread to the PAC at Victoria General Hospital in 2008 and, more recently, to Royal Jubilee’s clinical teaching unit. Both are showing promise of results similar to the initial pilot at the Royal Jubilee PAC. Medication reconciliation during discharge from hospital is another important issue. A multi-disciplinary team has been formed to begin the process of implementing medication reconciliation in the Royal Jubilee emergency department to improve patient safety and quality of care when transitioning patients to another facility or back into the community. Future plans involve administering the medication reconciliation program electronically.

For more information, please contact Cynthia Turner (Clinical Pharmacist, Medical Reconciliation) at or Dr. Richard Bachand (Manager, Clinical Pharmacy Programs) at