Observational studyJournal of patient safety2025
Challenges and Opportunities in the Medication Reconciliation Process in an Emergency Department: An Observational Human Factors Study.
Observational study in Journal of patient safety, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
2 citing papers in PubMed.
- An Underrecognized Problem: Missed and Delayed Carbidopa-Levodopa Administration in Emergency Department Patients With Parkinson's Disease.Academic emergency medicine : official journal of the Society for Academic Emergency Medicine · 2026Article
- Impact of clinical pharmacist-led medication management and education on tacrolimus therapeutic control.Frontiers in medicine · 2026Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
11 authors.
Funding
Abstract
objectivesThis 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.
methodsAn 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.
resultsSystemic 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.
conclusionsMedication 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.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.