Challenges and Opportunities in the Medication Reconciliation Process in an Emergency Department: An Observational Human Factors Study

Abstract

Objectives:

This observational study examines challenges and opportunities in the medication reconciliation process within the emergency department (ED). Through a human factors approach, we look to identify barriers and potential improvements for enhancing patient safety during transitions of care for older adults.

Methods:

An observational study was conducted in the ED of a large teaching hospital, comprising 32 hours of observation across 12 sessions. Researchers followed pharmacists, nurses, and triage staff, documenting workflows, communication practices, and medication reconciliation processes. Recurring patterns, challenges, and opportunities for improvement were identified through a qualitative analysis.

Results:

Systemic barriers to effective medication reconciliation were identified, including fragmented workflows, inconsistent documentation, and usability issues in electronic health records. Challenges were exacerbated by the fast-paced ED environment and frequent interruptions. Pharmacists played a pivotal role in synthesizing diverse information sources to construct accurate medication histories, but their workload often limited their capacity to address broader medication safety concerns. Opportunities for improvement include delegating specific tasks to trained support staff, optimizing electronic health record functionalities, and fostering interdisciplinary collaboration to streamline workflows and reduce errors.

Conclusions:

Medication reconciliation in the ED is critical for patient safety but faces significant systemic and environmental challenges. Addressing these barriers through enhanced system integration, task delegation, and improved communication protocols could increase efficiency and reduce errors. Further research is needed to evaluate these interventions across diverse ED settings to optimize medication reconciliation processes and improve safety outcomes.

Medication reconciliation is widely recognized as a key strategy for reducing harm at care transitions—when patients are moved between health care settings or providers. Our Agency for Healthcare Research and Quality-funded patient safety learning lab takes an interdisciplinary approach to investigate the causes and consequences of medication issues, including the operational complexities that shape and constrain care transitions work. As a first step towards this goal, this paper reports our observations at an emergency department (ED) of a large teaching hospital.

The fast-paced work environment, unpredictable nature of patient conditions and flow, and frequent use of high-risk medication, often make medication errors, such as drug omission, improper dose/quantity, and unauthorized drug administration, common occurrences in the ED.^1,2 The Institute for Healthcare Improvement recommends 3 steps to medication reconciliation: verification, clarification, and reconciliation³ (see Table 1). Pharmacy-led medication reconciliation in the ED has been shown to correct a large number of errors,⁴ to significantly improve accuracy and reduce discrepancies in medication histories,^5,6 and to reduce ED re-visits.⁷

TABLE 1.

The Institute for Health Care Improvement’s 3 Steps of Medication Reconciliation³

Verification	Clarification	Reconciliation
Obtaining a medication history from the patient and other appropriate sources, including current medications and those the patient should be taking. The compiled list should then be reviewed with the patient or caregiver.	Assessing the listed medications and doses for appropriateness.	Comparing the home medication list to new medications ordered during hospital or clinical transitions, most notably during admission and discharge.

Although the benefits to pharmacist-led medication reconciliation in the ED are clear, there is limited research supporting best practices for integrating this work into ED workflows and identifying the challenges and opportunities for further reduction of medication harm.

ED visits often mark the start of a hospital stay but can represent a significant transition point within a larger cycle of hospital admissions and readmissions, especially for older adults with chronic conditions and/or polypharmacy. These complexities present additional challenges for the diagnosis and treatment of acute illness in ED, reinforcing the need for medication reconciliation to help prevent adverse drug events both during and after ED care. By observing the work of ED pharmacists and nurses through the lens of human factors, our study aims to identify system-level barriers and opportunities to improve medication safety during transitions of care.

METHODS

This study was part of a larger ongoing project exploring medication safety processes across different care units within a hospital through observations and contextual inquiries of clinical staff at work. The study was conducted between July and August 2024 with approval by Institutional Research Board of the State university of New York at Buffalo (IRB study #00008175) and by the hospital’s Research Ethics Committee.

Setting

Observations took place in the ED of a tertiary teaching hospital. The hospital is designated a level 1 adult trauma center with 573 in-patient beds, serves over 70,000 patients a year, and has a capacity of 54 beds with 2 triage rooms. Each pod has patient rooms around the perimeter, and a central area where staff access computers, patient charts, and other administrative resources.

Participants

A purposive sampling approach was used to recruit ED clinical staff, with assistance from department heads. Nursing managers introduced the ED structure during an initial on-boarding meeting before team observations. Research objectives were discussed with nursing managers to identify the clinical roles for targeted observations: triage nurses, ED nurses (in pods), and ED pharmacists.

Eight nurses and 2 pharmacists were consented. During observations in the triage rooms, a physician providing in situ assessment to support patient-flow management also consented. Patients present during observations were not consented as no patient data was collected. Consented staff informed patients of their option to decline being observed by researchers.

Data Collection

Thirty-two hours of observations over 12 sessions were conducted, after triage nurses (3 sessions, 5 total hours), ED nurses (3 sessions, 7 total hours), ED command center (1 session, 2 h) and ED pharmacists (5 sessions, 18 total hours) performing their work. Observations all occurred between 11 am and 3 pm on nonsequential days over a period of 2 months. Dates and times were selected based on availability of researchers and consented staff. Each clinician was observed by 1 to 2 researchers, with each taking detailed, hand-written field notes. These notes were unstructured beyond a heading describing the date, location, and staff participant study number associated with each observation.

Observations followed 3 sets of ED roles: triage, ED nursing, and ED pharmacists. While observing triage and ED nursing work, researchers shadowed consented staff introduced by the nurse manager at the beginning of each session and followed various nurses to patient interactions whenever possible. Before observations of ED pharmacists, the head ED pharmacist provided an overview of the system and work functions.

Data collection included taking detailed, unstructured field notes, documenting work processes and observations with a focus on medication-related activities. Although the team was careful not to disrupt patient care, participants were encouraged to explain their processes whenever possible.

Researchers independently transcribed notes after observations to ensure preservation of context and data clarity.

Data Analysis

We took a team approach to analyze recurring themes and patterns in the data. The first 4 authors reviewed the combined observations together using Excel spreadsheets. Codes were iteratively refined into subcategories and themes to capture information about organizational structure, workflow and processes, limitations, and individual strategies/behaviors. The data and the associated codes were then brought to the larger team comprising medical, pharmacy, nursing, and system engineering researchers for discussions to achieve consensus and identify key insights emerging from analyses.

There was no attempt to quantify data about occurrences of particular incidents or contents, as observations were largely unstructured. When multiple researchers observed the same sessions, observations were coded separately despite overlap, as the goal was to gain a comprehensive understanding.

RESULTS

We organize our observations under several key categories.

Medication Reconciliation Workflow and Processes

Researchers observed three distinct yet critical medication-related processes in the ED. The term “Med-history” comprised the bulk of the pharmacists’ work and refers to the creation an accurate medication list from various sources (the Verification step in the IHI definition—see Table 1). Prescribers used a “Med-rec” process to compare the patient’s medication history (as documented in the electronic health record, including the above “med-history”), with the medication orders prescribed for use in the ED or for hospital admission (IHI’s Reconciliation step). “Med-verification” referred to a pharmacist assessing the appropriateness of medication orders originating in the ED before administration.

Although med-history is intended to be performed before med-rec, it was not uncommon for providers to perform med-rec first, with incomplete or inaccurate information. This issue was exacerbated by usability issues in the EHR interface that hides the time history of changes in the medication history such that providers may not have been aware that the med-history had not been completed.

Another challenge occurred specifically at night, when pharmacists are not present in the ED. When possible, med-histories were conducted the next morning, providing an opportunity for improving medication safety for patients transitioning out the ED into the hospital. However, med-verifications were conducted retrospectively, meaning that administration may already have happened. Finally, we found that the IHI-recommended medication Clarification process was not fully addressed in the work observed. Both provider-led “med-rec” and pharmacist-led “med-verification” were concerned with the appropriateness of new medications and doses administered in the ED, rather than the appropriateness of the home medications. However, one pharmacist mentioned that “…strict definition of med history doesn’t include changes to meds, but a pharmacist will often include notes of potential changes to ED and/or inpatient providers.” This comment indicated some considerations regarding home medications, but further inquiry revealed that no protocol was in place to examine home medications for potential medication harms that are not immediate to the patient’s status in ED.

Interestingly, there is a protocol to review medications against the Beers criteria for patients who experience a fall while in the ED. However, although this pharmacist commented that a comprehensive review of all home medications for fall risks would be beneficial, this would add to an already overwhelming workload. They also noted potential challenges in effectively communicating such information across different levels of care using the existing system and technology.

In addition, pharmacists were regularly called to support trauma patients arriving at the ED, provide consults, and perform other time-sensitive functions. These activities fall outside the scope of medication reconciliation work yet pose potential interruptions to medication-related workflow. For example, obtaining a patient med-history involves ad hoc, nonstandardized note taking during patient/caregiver interviews, requiring transcribing into formal EHR records; if transcribing is interrupted, crucial medication history details could be lost.

Clinical Team Interactions

Observations suggest that the medication history was often taken by multiple ED staff for different purposes, which may generate fragmented pieces of information that are not always documented or utilized across the department. Besides pharmacists, triage nurses inquired about medication history while assessing patients’ symptoms and vitals. Although the extent of these histories varied by nurse and the patients they were assessing, it was clear that the focus was on medications that carry immediate risks, such as blood thinners, due to the bleeding risks associated with acute injuries and, per their policy, medications that may be hazardous to the ED staff.

In the treatment areas (pods), nurses primarily focused on patient care and only inquired about medication history selectively including a routine inventory upon admittance or to confirm dosages and details, such as recent anticoagulant use. We observed few instances where ED nurses in pods were looking up notes in medication histories left by triage nurses, confirming medication details. Otherwise, work focused on stabilizing and caring for patients as they waited to be admitted or discharged. We found that the official medication reconciliation process was primarily completed in collaboration between the ED pharmacist and physician, as described earlier. This was confirmed by the ED pharmacist who noted that information obtained from the triage and pod nurse are commonly ignored as they felt that those staff may not have known what specific questions to ask.

Lastly, regarding communication across the ED team, the command center may have played a role. This small central unit, with 1 or 2 nurses stationed, served to direct patient flow and coordinate interaction between the various clinical teams. Triage acuity scores were used to determine allocation of patients to beds and manage staffing levels. This unit also coordinated responses to incoming trauma cases and other patient-flow-oriented tasks. Although the work of nurses in this command center work was minimally involved in the medication reconciliation work of interest, their coordination of the ED staff played a significant role in workload and team communication overall that may have contributed to the process of ensuring medication safety, but this needs to be further explored.

Sources and Quality of Medication History Information

Observations of both triage nurses and pharmacists showed the complexity of medication history due to the number of sources involved and the uncertain quality of information.

If a patient had been previously admitted, the hospital EHR included the patient’s last known medication history. However, this information could be outdated and difficult to verify due to fragmentation of care and usability issues. Triage nurses indicated they did not automatically trust these prior histories, and efforts to update the information varied. They also noted that it may be challenging to obtain information directly from patients, due to their current state, memory, individual assumptions of relevance, and communication barriers (e.g., language).

A unique triage data source in the ED is the emergency medical technician (EMT). When involved, EMTs provided first-hand observations that might include the patient’s medication situation (e.g., missed doses). One nurse, however, commented that the EMT’s information was also subjective and potentially incomplete, thus they relied more heavily on patient provided data.

Providers stated that it was helpful when patients brought their medications, or a printed list of current medications, to the ED. We observed occasions where family and caregivers provided valuable information related to the patient’s medication regimen, although family members sometimes disagreed.

Constructing an accurate medication list required pharmacists to expertly navigate diverse information sources. They decided when to use specific data sources, identified uncertainties, and applied various communication strategies to query patients. This process involved synthesizing patient conditions, medication data, and contextual cues (such as substance abuse, specialist-required conditions, residence, and primary pharmacy) to identify missing or unaccounted for medications. One pharmacist described the process as a “scavenger hunt”, whereas another emphasized the importance of confirming medications from at least 2 sources.

Pharmacists consulted multiple areas within the EHR, accessing records and data from prior hospital stays, community pharmacies, online controlled substance monitoring programs, and local health information exchange services. They also consulted with patients, caregivers, medication lists, pill bottles brought to the ED, best practice resources like UpToDate, Lexidrug, and physically printed Medication Administration Records from the patient’s care facilities. ED pharmacists also sought information from community pharmacists. Depending on the external agency’s standard practice, pharmacists received needed information through phone calls, faxed information, or printed lists.

When interviewing patients or family, pharmacists used clinical and interpersonal skills to ask targeted, nonjudgmental questions. This approach elicited accurate medication histories, even from “less effective historians,” a term they used to describe patients with difficulty recalling details. Finalizing an accurate medication list demands complex cognitive work, where pharmacists must weigh the strengths and potential flaws of each source. As one pharmacist summarized, “There are 3 stories: what is in the system, what the patient tells you, and the truth”.

General Practices versus Individual Strategies and Behaviors

Pharmacists and nurses were aware of their distinct roles, and were guided by policies and protocols, yet exhibited individualized approaches in their tasks. Triage nurses generally followed a standard format when inquiring about medication histories and frequently asked: “Are you currently taking any medications?”, “Do you have any allergies?”, and “Have you received any IV infusions in the past month?” However, we observed nurses being strategic, probing patients about their chronic health conditions to elicit more information on medications. Notable variations were observed among triage nurses in their approach to documenting medication histories. Practices ranged from stating “see (printed) list” to comparing total medication counts or meticulously verifying each listed medication.

More generally, we saw that the kinds of reconciliation/reviews differed across ED roles, in ways that were appropriate given assigned function, expertise, and needs. For example, triage nurses focused on quickly assigning acuity scores whereas ED nurses focused on patient care, as exemplified through one triage nurse’s comment, “I’m only assigning acuity, I couldn’t care less what meds they’re on.” Pharmacists took a more detailed approach, reviewing multiyear prescribing reports to identify filled prescriptions. They might use prescription dates and durations to determine whether verification is needed, accounting for details such as how medications prescribed on an “as needed” basis may be used irregularly so may last longer than the prescribed durations.

System Limitations and Usability Problems

Several system limitations and usability issues were noted that may increase risks of medication errors. The most fundamental technology challenge pharmacists had in their “med-history” process was the lack of interactive features to help track progress. Pharmacists thus print medication lists and manually review and validate medication lists. Each pharmacist annotates the printed list with unique symbols to indicate whether a medication required confirmation, dose verification, was likely discontinued, or had already been confirmed by multiple sources. These personalized markings guided patient interviews and were updated further based on patient input.

We also found that some EHR interface elements provided ambiguous or misleading cues. For example, medications are “grayed-out” in the interface to signify a link to the medication history list; however, this was frequently misinterpreted by other staff as the medication being discontinued. In addition, when entering a new medication order, the autocomplete function provides a dropdown of options, presenting a risk of choosing incorrect drugs with similar names. Some prescribers deployed a workaround by appending the more commonly used medication names with dots or spaces to make it easier to search and identify. Another barrier to efficient medication ordering is that when providers order over-the-counter medications, notes must be manually added to include the dosage/regimen information not provided by the system.

Not surprisingly, there are also interoperability challenges, as EHRs are not well integrated across facilities or specialties, requiring pharmacists to search multiple platforms for a complete history. Transferring data between systems manually may result in errors, such as missing or inaccurate medication information. Medication lists in the EHRs were also often outdated, with some records dating back to 2015. Past reconciliation entries also persist in the system, and clutter the interface, misleading pharmacists to start verifying out-of-date information before realizing and restarting the reconciliation process. These data management issues add to pharmacists’ workload as they are also deleting out-of-date records and manually checking medication histories against several sources in their work. Finally, it was noted that alerts are lacking for critical cases, such as for geriatric patients with a fall in ED who therefore require medication review. There is also no clear process for transferring this information to primary care.

DISCUSSION

The ED work environment is fast-paced, dynamic, and characterized by high levels of unpredictability. Often operating under significant time pressure and with limited information, ED clinicians prioritize rapid decision-making and patient stabilization. In contrast, medication reconciliation requires careful analysis of information from disparate sources to determine a patient’s accurate medications. From a human-system integration perspective, the observed misalignment between ED providers and pharmacists during the ED medication reconciliation process (often conducted in a nonoptimal sequence) suggests a need to reimagine the workflow and task distribution to better align with the unique demands of the ED.

For example, we observed pharmacists spent most of their time compiling and assessing medication histories from multiple sources, using strategies that relied more on their communication and investigative skills than on their specific pharmaceutical knowledge. Thus, we question whether much of the medication history investigation could be delegated to other trained staff (e.g., pharmacy technicians). ED pharmacists could focus on higher-level tasks, such as assessing home medication appropriateness. During observations, we did not identify any prospective procedures to correlate the med-rec history with potential adverse medication effects such as falls or altered mental status risks.

The role separation for medication history verification could also invite a more holistic approach, after a patient from arrival to transitioning out of ED. Yet, observations revealed that patients (and family/caregivers) were asked about their medication history by care team members at different time points. Although clinicians may understand each question’s purpose, patients might not perceive the overall continuity of the process as repeated questions can be confusing and frustrating. This might lead to duplicated efforts and/or fragmented information, complicating reconciliation efforts.

Another observed challenge is the complexity of working with “multiple truths”. Patients, family, caregivers, EMTs, and multiple EHR systems often provide differing perspectives of a patient’s medication history. By the time patients transition to inpatient care, certain questions may appear resolved, but contextual clarity is often lost, leaving uncertainties about what is known and unknown. This lack of clarity creates a patient safety risk if inpatient teams rely on incomplete or conflicting information. Ideally, ED medication data during care transitions should be treated as a preliminary starting point rather than a definitive source, recognizing its inherent limitations.

Transitions back to primary or community care from ED have similar challenges. Ideally, the reconciled or “true” medication list follows the patient upon their next transition of care whether that be to a higher level of care within the hospital or discharged from the ED back to the community and primary care. Pharmacists also need a system to support them in communicating potential medication harms with providers and pharmacists outside the hospital.

Some of the issues we observed are well documented in the literature. Interruptions to med-rec workflow have been identified to significantly increase prescribing error rates among emergency pharmacists, although a study showed that higher scores on a working memory capacity test did mitigate these effects.⁸ Human factors research on managing work interruptions in nursing (see^9–12) could provide insights into improving interruption management for ED pharmacists. Similarly, extensive research has examined EHR usability issues, including alarm design, difficulty finding data, ineffective language use, and poor integration with clinical workflow (see^13–15). Suggestions from this work that may address the identified usability issues include flexible data entry, notices on out-of-date data, and reducing the use of text templates. Although a user-centered approach informed by this literature is essential for maximizing EHR benefits and minimize unintended consequences, a more systematic work analysis of clinical roles, such as the ED pharmacy work, will help ensure effective EHR system design that does not add to the clinicians’ already high workload.

We recognize that our observations, coming from a single ED, is not representative of EDs nor the involvement of pharmacists in ED work. Other hospitals may have other workflow, including different roles assigned to medication reconciliation and different technology applied. This presents opportunities for future research to study the strengths and limitations of different team and work approaches in ED.

CONCLUSIONS

This work highlights challenges and opportunities in ED medication reconciliation, emphasizing systemic barriers compounded by the fast-paced nature of this environment. Here, ED pharmacists play a crucial role in navigating information sources to construct accurate medication histories, yet this heavy reliance on them may not be sustainable. Delegating specific tasks to trained support staff and improving EHR functionalities offer the potential to increase efficiency and safety. In addition, standardized protocols and interdisciplinary collaboration can aid in addressing fragmented information and improve continuity in patient interactions. Although limited to a single ED, findings provide actionable insights and note the need for further research to optimize workflows and enhance patient safety during transitions of care for older adults.