The impact of medication reconciliation at transitions of care on healthcare outcomes : an evidence-based approach

Abstract

Introduction: Communication breakdowns during transitions of care contribute significantly to medication errors and adverse drug events. Unintended medication discrepancies account for over half of these errors, with drug omissions being most frequent. Medication reconciliation (Med Rec), endorsed internationally as a patient safety strategy, ensures accurate medication histories and continuity of care. In Malta, formal Med Rec is not yet mandated and local impact data is limited. This Critically Appraised Topic summarises high-level international evidence to explore the potential role of Med Rec within the Maltese healthcare context. Methodology: A structured literature search was conducted across PubMed, the International Pharmaceutical Abstracts, and the Cochrane Database of Systematic Reviews to identify systematic reviews and meta-analyses published between 2015 and May 2025 evaluating Med Rec at hospital transitions. Date limits were set from 2015 to May 2025, and language was restricted to English. A total of six studies met the inclusion criteria: two overviews of systematic reviews and four systematic reviews, while forty-four studies were excluded for not meeting the eligibility criteria. Results: The studies evaluated process, patient-related, and healthcare utilisation outcomes. Evidence was of moderate to very low certainty, showing a positive effect on the reduction of medication discrepancies. Med Rec consistently improved process-related outcomes by intercepting and clarifying medication discrepancies, thereby enhancing continuity of care. Effects on patient-centred outcomes and clinical utilisation measures remain uncertain, as these were often secondary endpoints and studies were underpowered to detect meaningful differences. In addition, Med Rec was frequently delivered as part of bundled interventions, making it difficult to isolate its specific contribution. Conclusion: While current evidence supports Med Rec as a mechanism for improving medication accuracy, its direct effect on clinical outcomes remains inconclusive. Further research rather than implementation is indicated at this stage. A local risk assessment to quantify the prevalence and impact of unintended medication discrepancies, particularly in high-risk cohorts such as older adults and patients on polypharmacy should be prioritised. Such baseline evidence would guide future feasibility assessment and support an evidence-based, phased approach to Med Rec implementation into the national healthcare system.