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Medication reconciliation

Compare admit/discharge meds with RxNorm matching and discrepancy flags.

Rx · Inpatient Pharmacy · Reconciliation Worksheet

Medication Reconciliation

Mercy Hospital · 4/27/26 discharge · AFib + asthma exacerbation
PHARMACIST DESK
Discrepancies
6
RxNorm matched
12/12
Critical interactions
1
Resolved
0/6

Home medication list

From last clinic visit · 4/12/26

860975MetforminBiguanide
500 mg · BID
314076LisinoprilACEi
20 mg · Daily
617312AtorvastatinStatin
40 mg · QHS
243670AspirinAntiplatelet
81 mg · Daily
329498Albuterol HFASABA
90 mcg · PRN

Hospital discharge list

Mercy Hospital · 4/27/26 discharge

860975MetforminBiguanide
1000 mg · BID
314076LisinoprilACEi
20 mg · Daily
859749RosuvastatinStatin
20 mg · QHS
1364430ApixabanDOAC
5 mg · BID
329498Albuterol HFASABA
90 mcg · PRN
8640Prednisone taperGlucocorticoid
40 mg → 0 · 5d taper
896188Fluticasone/SalmeterolICS/LABA
250/50 mcg · BID

Reconciliation Worklist

Dose changeModerate
Metformin 500 mg BIDMetformin 1000 mg BID
Metformin uptitrated 500 → 1000 mg BID for A1C 8.4.
Rationale: A1C 8.4 inadequately controlled; eGFR 71 supports uptitration.
Therapeutic subModerate
Atorvastatin 40 mg QHSRosuvastatin 20 mg QHS
Atorvastatin → rosuvastatin 20 mg (intensification).
Rationale: LDL 142 above secondary prevention goal; equipotent intensification.
DiscontinuedCritical
Aspirin 81 mg Daily
Aspirin DC'd, overlapping bleed risk with new apixaban.
Rationale: Triple-overlap bleed risk; ASA not indicated for stroke prevention in nonvalvular AFib on DOAC.
NewMajor
Apixaban 5 mg BID
Apixaban 5 mg BID for new-onset AFib (CHA2DS2-VASc 4).
Rationale: CHA2DS2-VASc 4 → anticoagulation indicated. CrCl >30, age <80, weight >60 kg → standard dose.
NewMajor
Prednisone taper 40 mg → 0 5d taper
Prednisone taper for asthma exacerbation.
Rationale: Short course steroid burst; complete by 5/2.
NewModerate
Fluticasone/Salmeterol 250/50 mcg BID
Started ICS/LABA after second exacerbation in 6 mo.
Rationale: Step-up per GINA; controller therapy added.
Drug-Drug Interactions
Apixaban + AspirinCritical

Mechanism: Additive antiplatelet/anticoagulant bleed risk

Action: Discontinue ASA unless ACS/recent PCI.

Rosuvastatin + ApixabanInfo

Mechanism: Minimal CYP overlap

Action: No adjustment needed.

Prednisone + MetforminModerate

Mechanism: Steroid-induced hyperglycemia

Action: Monitor BG q6h during taper.

Pharmacy · Inpatient

Med reconciliation discrepancies & pharmacist workload

What's getting flagged on admit/discharge and how fast pharmacy is clearing it.

Synthetic data

Discrepancy types

Omission121
Dose mismatch84
Duplicate therapy52
Frequency error31
Wrong route24

High-severity examples (today)

  • Warfarin 5mg → 10mgDose mismatchResolved
  • Metformin missing on admitOmissionIn review
  • Dual SSRIs (sertraline + escitalopram)DuplicateResolved
  • Insulin glargine wrong frequencyFrequencyIn review

Connectors used

e-Prescribing

required

Photon / DoseSpot

Pull Surescripts medication history

Clinical Terminology

required

RxNorm, ICD-10, SNOMED, LOINC, OpenFDA, ClinicalTrials.gov

RxNorm matching and dedup

Health Records

optional

Redox / Particle Health

Write reconciled list back to the chart

Microsoft Excel

optional

Pharmacist QA exports