Medication reconciliation: an important piece of the medication puzzle.

Medication errors continue to cause significant morbidity and mortality. This, in turn, costs the health care system millions of dollars each year in preventable costs. Medication reconciliation, an important piece of medication therapy management (MTM), is vital to reducing medication errors. By verifying, clarifying, and reconciling medications at each point of care, pharmacists can play a vital role in improving health care and lowering costs. This case study describes an MTM session with a 66-year-old Caucasian female who is referred by the nurse practitioner in the clinic for pharmacist services. The patient has a history of portal hypertension, alcoholic liver damage, and chronic obstructive pulmonary disease. After obtaining a detailed history, the pharmacist identified significant medication-related problems including polypharmacy, nonadherence, drug-alcohol interactions, and inappropriate use of medication. After discussions with the patient and her nurse practitioner, a medication plan was created for the patient to follow.