Medication Reconciliation Across Cancer Prescribers

This page is for people with cancer and the families who help manage their medicines. It explains medication reconciliation, the careful check of your medicine list, and how to keep that list accurate as your care changes.

AHRQ's Patient Safety Network gives the formal definition. It is "the process of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care."

In plain terms, someone compares what you were really taking against what is now written down, then fixes the gaps.

AHRQ names three points in a hospital stay where the list must be checked.

• Admission.
• Transfer between units inside the hospital.
• Discharge.

AHRQ explains why these moments go wrong. Hospital clinicians "might not be able to easily access patients' complete pre-admission medication lists." The result is omissions, duplications, or incorrect dosages.

AHRQ also says medication discrepancies after discharge are among the most common kinds of adverse events. It adds that reconciliation alone has not been shown to reduce readmissions, so it works best alongside other safety steps.

Cancer care multiplies every part of the problem.

You may have several prescribers at once, such as medical oncology, primary care, surgery, radiation oncology, and pain or palliative care. One may not see what another has prescribed.

Ask specifically whether any of your medicines come from a specialty pharmacy rather than your usual one. If so, they may be missing from the record other clinicians look at.

Ask too about the medicines that change shape over time. A steroid dose that steps down, a medicine taken only as needed, and a drug taken on certain days of a cycle are easy to get wrong on a list. Check each one line by line.

Do not build the list from what you remember. Build it from things you can hold.

Bring the actual bottles and boxes. A bottle carries the strength, the prescriber, the fill date and the pharmacy. Memory carries none of that reliably.

Add your pharmacy printout, your last discharge summary, and anything a specialty pharmacy sent you.

MedlinePlus suggests keeping it simple and physical: "Make a medicine chart. List each medicine and the time that you take the medicine."

Give each medicine its own line, and put all of this on it.

• The drug name, both brand and generic.
• The strength, per tablet, capsule or milliliter.
• How many, how often, and at what times.
• What it is for.
• Who prescribed it.
• Which pharmacy fills it.
• Whether you actually take it as written.

That last item is the one most lists get wrong. If you skip the evening dose because it keeps you awake, that belongs on the list. A list that records the intention rather than the reality is the one that causes harm.

Ask the pharmacist to check for duplicates directly. AHRQ lists duplicate therapies among the problems, and a brand name and a generic name for the same drug are an easy way to get two of something.

NCI's guidance on keeping cancer records includes "other supportive or complementary care received." Supplements are not a side note.

NCCIH is direct about the best-known example. "It has been clearly shown that St. John's wort can interact in dangerous, sometimes life-threatening ways with a variety of medicines."

NCCIH also names cancer drugs specifically. St. John's wort can weaken the effects of many medicines, "including irinotecan, imatinib, and docetaxel."

Read that carefully, because it inverts the usual worry. The danger is not only that a supplement might add a side effect. NCCIH says it can weaken some cancer medicines. Tell your oncology team about every supplement before you start it, and do not stop or start anything on your own.

FDA says grapefruit juice can interact with some drugs.

The mechanism is worth knowing. Grapefruit juice blocks an enzyme called CYP3A4 in the small intestine. As FDA puts it, "the juice lets more of the drug enter the blood. When there is too much drug in the blood, you may have more side effects."

FDA lists affected groups, including:

• Statins such as Zocor and Lipitor.
• Some blood pressure drugs.
• Transplant anti-rejection drugs.
• An anti-anxiety drug.
• Certain corticosteroids.
• Heart rhythm drugs.
• One antihistamine.

It can also work the other way. With fexofenadine, grapefruit juice "can cause less fexofenadine to enter the blood."

MedlinePlus adds a simpler point that people miss. "Some medicines need to be taken when your stomach is empty." Ask your provider or pharmacist which of yours are affected by food.

The list you go home with is not the list you came in with. Something almost always changed.

Do not restart a medicine the hospital stopped without asking why it was stopped. A medicine can be paused for a short time or stopped for good, and only your team can tell you which.

Ask these four questions before you leave.

• Which of my medicines were stopped, and permanently or temporarily?
• Which had the dose changed?
• Which are brand new?
• Which bottles at home should I now stop using?

Then ask for the answers written on the discharge paperwork, not spoken at the door.

Reconciliation only works if one person resolves the conflicts. Ask who that is, by name and role. It may be a pharmacist or another member of your team.

If nobody owns it, four prescribers will each assume another one is handling it, and none of them will.

NCI's guidance on tracking cancer care says to record:

• Dates of each medical visit.
• Tests and procedures received, with dates and results.
• Treatments received, with dates.
• Side effects and symptoms you have had, with dates.
• Any medicines prescribed.
• Other supportive or complementary care received.

Keep copies of treatment plans and results too. NCI suggests a file folder, or photos saved on your computer. Either works. A personal health record can also help.

• Who is the one person who reconciles my medicine list?
• Are any two of these the same drug under different names?
• Does anything on this list interact with my cancer treatment?
• Do any of my supplements need to stop, and when?
• Which of these must be taken with food, and which without?
• What should I do if I miss a dose of the oral cancer drug specifically?

That last question deserves its own answer from oncology, not from a general leaflet. The rule for a missed dose is not the same for every drug.

• Medication Reconciliation — AHRQ Patient Safety Network
• Managing Cancer Costs and Medical Information — National Cancer Institute
• St. John's Wort and Depression: In Depth — National Center for Complementary and Integrative Health
• Grapefruit Juice and Some Drugs Don't Mix — U.S. Food and Drug Administration
• Taking medicines as prescribed — MedlinePlus Medical Encyclopedia
• Managing Cancer Care — National Cancer Institute