Clinical Pharmacist-Led Medication Reconciliation During Intra-Hospital Transfer Among High-Risk Internal Medicine Patients: A Practical White Paper

Abstract

Medication discrepancies during intra-hospital transfer are a significant patient safety concern, particularly among high-risk adult internal medicine patients. Changes in the level of care, medication regimens, and clinical responsibility increase the risk of unintended omissions, duplications, dosing errors, and other clinically significant discrepancies that may compromise continuity of care and contribute to adverse drug events. Although medication reconciliation is well established at hospital admission and discharge, intra-hospital transfer remains an underrecognized transition requiring a standardized approach. This white paper proposes a practical, standardized, and risk-based clinical pharmacist-led medication reconciliation model for high-risk adult internal medicine patients undergoing intra-hospital transfer. The proposed framework defines the roles and responsibilities of clinical pharmacists, outlines practical criteria for identifying patients requiring prioritized review, presents a structured medication reconciliation workflow, and provides implementation tools, including a standardized medication reconciliation checklist and documentation template. In addition, key performance indicators are proposed to support implementation, quality monitoring, service evaluation, and continuous improvement. The proposed model aims to improve medication safety, strengthen continuity of pharmacotherapy, enhance communication among healthcare professionals, and reduce clinically significant medication discrepancies during intra-hospital transfer. By providing a structured framework that can be adapted across different hospital settings, this white paper supports healthcare organizations in implementing consistent medication reconciliation practices and advancing safer transitions of care.