Medication reconciliation documentation and documented discrepancies in a tertiary Saudi hospital: a retrospective observational study

INTRODUCTION: Medication reconciliation is a key patient-safety process during transitions of care, but its routine documentation and associated medication-list findings are not well described in Saudi tertiary hospital practice. This study aimed to characterize medication reconciliation documentation, documented medication discrepancies, and documented medication-list modifications at King Saud University Medical City (KSUMC). METHODS: A retrospective observational study was conducted using routinely collected electronic health record data for hospitalized patients at KSUMC between June 2023 and June 2024. Eligible records contained the medication-related fields required for analysis, including home medications at admission, medications documented during hospitalization, medication reconciliation documentation status, documented discrepancy status, discharge medication information, and documented medication modification status. Patient-level outcomes used the study population denominator (N = 471), whereas medication-level modifications used the reviewed medication-record denominator (N = 2641). Descriptive statistics were calculated using R software (version 4.4.3). RESULTS: A total of 471 patients were included. Mean age was 46.1 years (SD 18.3), and 58.6% (276/471) were male. Medication reconciliation was documented in 20.8% (98/471) of records. The mean number of home medications at admission was 4.5 (SD 3.4), and the mean number of medications documented during hospitalization was 5.3 (SD 3.8). At least one documented medication discrepancy was identified in 3.8% (18/471) of patients. Documented medication modifications were recorded for 6.5% (172/2641) of reviewed medication records. CONCLUSION: Medication reconciliation was documented in only one-fifth of reviewed electronic records, indicating an important documentation gap in routine practice. The distinction between patient-level discrepancies and medication-level modifications should be maintained in future audits. More standardized electronic documentation, including a mandatory reconciliation checklist at admission and discharge, may improve the visibility and auditability of medication reconciliation at KSUMC.