Reflections on common medication reconciliation practices impacting a case of discounted thyroid replacement hormone

Quality problem or issue: Medication errors related to reconciliation processes. Initial assessment: Even though most US medical centers utilize medication reconciliation processes to reduce medical errors, adverse events related to medications continue to occur causing extra burden on the US healthcare system. New strategies toreduce medication errors are being implemented, including pharmacy-based medication reconciliations. Case report: An 86-year-old female was admitted for symptomatic bradycardia in the setting of a fall. During her hospitalization, she was evaluated for pacemaker implantation until her thyroid-stimulating hormone blood test revealed severe hypothyroidism. Medication reconciliation had been performed twice with the patient, and her family adamantly affirmed the patient was complianton her levothyroxine. Upon further investigation, she had changed pharmacies nine months prior to her hospitalization andwas obtaining her thyroid replacement hormone from an online Canadian pharmacy. Once restarting Synthroid, her symptomsimproved allowing her to forego the procedure. Lessons learned: Physicians must understand common pitfalls with rapidly verifying home medications against electronicmedical records as patient knowledge of their home therapies is often inaccurate in combination with non-updated electronicdata. Hospitals are evaluating strategies such as pharmacy-based medication reconciliations to reduce adverse events related tomedication errors, which can decrease hospital costs and improve patient outcomes. Knowing which pharmacy is dispensing themedications can prove useful as discounted medications from online pharmacies may lack efficacy.