Table.3 Examples of reconciliation errors (REs) detected in the medication history
From: Value of pharmacy services upon admission to an orthopedic surgery unit
RE type | RE example | Severity/clinical significance |
|---|---|---|
Omission | A patient with hypertension was admitted for ankle fracture surgery. His medication (valsartan/hydrochlorothiazide 160Â mg/12.5Â mg PO daily) was not ordered for him upon admission | Clinically significant |
Incorrect dose | A patient with hypertension was admitted for right foot capsulotomy. His medication dose (moxonidine 0.2Â mg PO twice daily) was incorrectly ordered for him as moxonidine 0.3Â mg PO twice daily | Clinically significant |
Incorrect frequency | An elderly patient with multiple comorbidities was admitted for right hip fracture with betahistine 16Â mg PO daily dose. At home, he was on betahistine 16Â mg PO twice daily | Clinically insignificant |
Wrong medication | A patient with diabetes mellitus was taking at home insulin glargine 16 units subcutaneously at night. Upon admission, he was incorrectly ordered insulin regular sliding scale instead of his basal regimen (insulin glargine) | Serious |