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Continuity of medication management

A patient’s medicines are reviewed, and information is provided to them about their medicines needs and risks. A medicines list is provided to the patient and the receiving clinician when handing over care.

There are multiple points of vulnerability in the medication management pathway when communication and focused partnership with the patient and/or their carer can contribute to achieving the best treatment outcome.

Medication review

Health service organisations need to consider how medication review, including medication reconciliation, can be built into existing work practices.

Medication review is a multidisciplinary responsibility and should be person centred. It ensures ongoing safe and effective use of medicines at all stages of the medication management pathway, including at the point of prescribing, dispensing and administering a medicine. Clinicians need to have the skill and expertise to conduct medication review, and have sound practices and processes for communication to implement recommended changes.

A well-structured medication review will minimise medicine-related problems and optimise the intended therapeutic outcomes for patients. Delivery models will vary across health service organisations. Medication review may need to be given a higher priority for patients with a higher risk of experiencing a medicine-related problem.

Medication review includes1:

  • Prescription review – a technical review of a patient’s medicines (for example, anomalies with medicine orders or prescriptions)
  • Concordance and compliance review – a structured review to consider issues relating to a patient’s medicines-taking behaviour (also called review of medicines use)2
  • Clinical medication review – a structured review of medicines and clinical ‘condition’ with the patient (and/or their carer); an outcome of review could be cessation (or ‘deprescribing’) of a medicine.

Some reviews of a patient’s medicines may be unstructured and opportunistic, with or without the patient’s or carer’s involvement.2 These might include an isolated question or issue raised by a patient or clinician; clarification about a dose, formulation or name of a medicine; or monitoring requirements of a medicine.

Medication review provides a mechanism to partner with patients to optimise medicine use. This can help patients to:

  • State their preferences and consider options to make fully informed decisions (links to Action 4.3)
  • Manage their condition
  • Improve their functional ability (for patients with long-term conditions)
  • Reduce the time they spend in the health service organisation or the likelihood of readmission
  • Enhance their quality of life, such as for patients with mental illness.

Information for patients

Patients and carers should be provided with enough information about medicine-related treatment options. This information needs to be in a form that is easy to understand and useful to patients.

Appropriate education and provision of written medicine-related information to patients are essential to encourage safe and effective medicine use, and promote adherence to treatment regimens. This may include the supply of a medicines list (or profile), education about the medicines and any changes, and consumer medicine information (CMI) leaflets.

When provided with quality information and education about medicines, many patients are able to:

  • Be involved in decision-making, and consider the options, benefits and risks of the proposed treatment
  • Make informed choices about their medicines – this is especially important when informed consent is required
  • Assist in medication reconciliation and prevention of errors by identifying medicine-related problems
  • Alert clinicians to suspected ADRs.

Providing information to patients is a multidisciplinary (medical, nursing and pharmacy) responsibility to ensure continuity of medication management.

Medicines list

Transfer of patients between clinicians, health service organisations and units within organisations provides opportunity for medication error if the communication of the patient’s medicine-related information is incomplete or inaccurate.

More than 50% of medicine-related incidents occur at transitions of care, and around one-third of these have the potential to cause harm.3,4 Omitting one or more medicines from a patient’s discharge summary exposes patients to nearly 2.5 times the usual risk of readmission to hospital.5

All clinicians, including doctors, nurses and pharmacists, have a role and shared responsibility to ensure that accurate and complete medicine-related information, in the form of a medicines list, is communicated whenever care is transferred.

The medicines charted on the NIMC are considered a current list (as long as this information is based on a BPMH that has been verified; see Actions 4.5 and 4.6), and any changes to medicines are documented during the episode of care. These changes may be part of the clinician’s decision-making process, or may be as a result of a recommendation following medication review.

Partnering with patients throughout the episode of care and providing a medicines list (accompanied by counselling) on discharge will:

  • Help patients adhere to their medicines
  • Empower patients and provide an opportunity to challenge the prescribing, dispensing or administration of potentially incorrect medicines
  • Reduce the risk of patients taking incorrect medicines when they are discharged to the community or when their care is transferred.


Medication review

Information for patients

Provision of a medicines list


  1. Clyne W, Blenkinsopp A, Seal R. A guide to medication review. Liverpool, UK: National Prescribing Centre; 2008 (accessed Sep 2017).
  2. Task Force on Medicines Partnership, National Collaborative Medicines Management Services Programme. Room for review: a guide to medication review – the agenda for patients, practitioners and managers. London: Medicines Partnership; 2002.
  3. Cornish P, Knowles S, Marchessano R, Tam V, Shadowitz S, Juurlink DN, et al. Unintended medication discrepancies at the time of admission to hospital. Arch Intern Med 2005;165(4):424–9.
  4. Sullivan C, Gleason K, Rooney D, Groszek J, Barnard C. Medication reconciliation in the acute care setting, opportunity and challenge for nursing. J Nurs Care Qual 2005;20(2):95–8.
  5. Stowasser D, Collins D, Stowasser M. A randomised controlled trial of medication liaison services – patient outcomes. J Pharm Pract Res 2002;32(2):133–40.
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