M E D I C AT I O N S A F E T Y R E C O N C I L I AT I O N

T O O L K I T
 Medication Safety Reconciliation 1

M E D I C AT I O N S A F E T Y R E C O N C I L I AT I O N

T O O L K I T

Developed by the North Carolina Center for Hospital Quality and Patient Safety© September 2006
PO Box 4449, Cary, NC 27519-4449

Portions of this Tool Kit are reproduced with permission of The Carolinas Center for Medical Excellence © October 2005.
The Carolinas Center for Medical Excellence, 100 Regency Forest Drive, Suite 200, Cary, NC 27511-8598
2 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

Acknowledgements

Thanks to those that have shared their time and expertise to help develop and produce
this tool kit. It is through their expertise, creativity and generosity of sharing their knowl-
edge and forms that we have been able to produce this tool kit for your use.

Specifically, thank you to:

Frank Federico Debra Miller, PharmD, BCPS

Director Cardiology Clinical Specialist
Institute for Healthcare Improvement Carolinas Medical Center
Cambridge, MA Charlotte, NC

Eric Jackson, MA Erica Morrison, MS

Lead Analyst Project Manager
The Carolinas Center for Medical Excellence NC Center for Hospital Quality and Patient Safety
Cary, NC North Carolina Hospital Association
Cary, NC
Meera Kelley, MD
VP Quality and Patient Safety Ryan M. Taylor, PharmD
WakeMed Health and Hospitals Medication Safety Officer
Raleigh, NC OSF Saint Francis Medical Center
Peoria, Il
Carol Koeble, MD, MS, CPE
Director
NC Center for Hospital Quality and Patient Safety
Vice President
North Carolina Hospital Association
Cary, NC

Additionally, thank you to the Institute for Healthcare (IHI) and The Carolinas Center for Medical Excellence (CCME) for their materials.

Barbara S. Edson, RN MBA, MHA

Quality Improvement and Patient Safety Professional/Consultant
NC Center for Hospital Quality and Patient Safety
North Carolina Hospital Association
Cary, NC
 Medication Safety Reconciliation 3

Ta b l e o f C o n t e n t s

Chapter 1: Introduction

Chapter 2: Assessment

Chapter 3: The Project

Chapter 4: Performance Improvement Model

Chapter 5: Spreading and Formalizing

Chapter 6: Reference Materials

4 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

1
I n t ro d u c t i o n

The Problem
A 72-year old female with a history of heart disease and atrial fibrillation was admitted to the hospital with pneu-
monia. Her prior medications included Warfarin 3mg daily, Lipitor 10mg daily, and Toprol XL 100mg daily.
While in the hospital she was under the care of the hospitalist physicians. She received Pravachol instead of
Lipitor as the hospital had a deal with the company to get Pravachol at much lower cost. Her PT (protime)
became elevated while receiving the antibiotic Levofloxacin, and her Warfarin dose was decreased to 2mg daily.
Upon discharge home, her physician wrote to D/C home on current meds, and she received a list and correspon-
ding prescriptions for Coumadin 2mg by mouth daily, Pravachol 40mg by mouth daily, Toprol XL 100mg by
mouth daily and Levoquin 500mg by mouth daily for 5 days. Ten days later she returned with severe body aches,
weakness and bright red blood per rectum. Her laboratory evaluation revealed a hemoglobin of 8.6, CPK of
3200, and a PT of 44. Her bag of medications included Coumadin 2 mg daily, Warfarin 3mg daily, Pravachol
40 mg daily, Lipitor 10 mg daily, and Toprol XL 100 mg daily. When asked why she was taking the Warfarin
and the Lipitor when they weren't on her discharge list, she explained that they had been prescribed by her cardi-
ologist who told her it was very important to keep taking these. Fortunately, her excess blood thinning and choles-
terol lowering medications were stopped and she recovered completely. She was given a list of medications that
also clearly specified which medications were to be stopped, and the information was communicated by phone
and fax to the cardiologist with whom she was to follow up.

Unfortunately, scenarios like this one are far too common in our healthcare system. It has been estimated that approxi-
mately 7,000 of these deaths are attributable to medication errors. 1

Scope of the Problem

• Incidence rates of adverse drug events (ADEs) range from 2 to 7 per 100 admissions.2
• Preventable adverse drug events are associated with one out of five injuries or deaths from errors, and are a result of
poorly designed systems, which often lack independent redundancies.3
• Medication errors are one of the leading causes of injury to hospital patients. Chart reviews reveal that over half of
all hospital medication errors occur at the interfaces of care. 4
• Up to 60% of patients will have at least 1 discrepancy in their admission medication history.5

Medication delivery in the hospital environment is a complex process consisting of prescribing, transcription, dispensing
and administration. Errors can and do occur during any step of this process. Over half (56%) of medication errors
occur during the prescribing process. 6
Medication errors occur 46% of the time during transitions, admission, transfer
or discharge from a clinical unit / hospital. 7

1. Michels R, Meisel S. Program using pharmacy technicians to obtain medication histories. American Journal Health System Pharmacy, 2003, Oct: 60:
1982-6.
2. Kaushal R, Bates D. The Clinical Pharmacist's Role in Preventing Adverse Drug Events, http://www.ahcpr.gov/clinic/ptsafety/chap7.htm.
3,7. Pronovost P, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Critical Care, 2003, Dec: 18(4):201-5.
4. Rozich JD, Resar RK. Medication Safety: One Organization's Approach to the Challenge. Joint Commission Journal of Quality and Safety, 2004, Jan:
30(1): 5-14.
5. Cornish P, et al. Unintended medication discrepancies at the time of hospital admission. Arch. Internal Medicine, 2005, Feb: 165: 424-29.
6. Bates et al, Incidence of adverse drug events and potential adverse drug events: implications for prevention, JAMA, 1995, Jul. 5; 274(1):29-34.
 Medication Safety Reconciliation 5

An important component of prescribing medication is accurate information on the patient's current medications or the
patient's medication history. Obtaining an accurate list of medications is difficult in today's complex and often frag-
mented healthcare environment. Compounding the difficulty of obtaining this list are the increasing age of the popula-
tion, the volume of medications available and used, and the level of medical literacy. Computerized physician order
entry (CPOE) is gaining momentum as a mechanism to reduce prescribing errors in American hospitals; however, in
order to be effective, accurate medication lists will need to be obtained.

The Solution
Standardize the Process
A standardized process that identifies the medication name, dose, route and frequency (medication history) and assigns
responsibility for obtaining this information establishes a consistent mechanism for medication information collection.
Comparing a medication history with physician medication orders and resolving any discrepancies is crucial in prevent-
ing prescription errors at transition points (admission, transfer or discharge). This cost-effective and efficient process is
referred to as medication reconciliation.

Medication Reconciliation
A formal three-step process that includes:
1. Obtaining a complete and accurate list of each patient's current medications (including name, dosage, frequency
and route)
2. Comparing the physician's admission, transfer or discharge medication orders to that list
3. Resolving any discrepancies that may exist between the medication list and physician order before an adverse drug
event (ADE) can occur

The three steps of the medication reconciliation process can prevent prescribing errors of omissions, wrong dosage
or frequency of medications, and duplicate orders of the same classification of medications.
A common, successful strategy that hospitals have used for medication reconciliation is a standardized form. The
form is often an admission intake, medication, or physician order form. The standardized form's components are med-
ication history or current medication list, the medication orders, the continuation or discontinuation of the medication,
and the reason for a medication discontinuation. There are examples of these types of forms at the end of this chapter.

Process Accountability
The medication reconciliation process involves both the patient and the healthcare providers. The patient or the
patient's family is a primary source of his or her medication history. The healthcare providers, the nurse, pharmacist
and physician, are involved in the steps of the process. The healthcare providers' level of involvement will vary accord-
ing to their process and institutional policy.
Assigning responsibility for each step of the three-step process is crucial to success. In the first step of the med-
ication reconciliation process, the nurse commonly gathers the information from various sources and records a medica-
tion history. Pharmacists are used in less than 5% of American hospitals to record medication histories, despite pharma-
cists' qualifications and expertise in the area of medication history taking. 8 Physicians are solely responsible for writing
the medication orders for the admission, transfer or discharge per their license.
The nurse, the physician and/or the pharmacist can do the second step in the reconciliation process which is com-
paring the medication order to the history and/or current medication list for transfers and discharge.
The third step, resolving any discrepancies that exist between the medication history (or current medication list for
transfers and discharge) and the medication orders, can also be done by the nurse, the physician and/or the pharmacist.

8. Gleason KM, et al. Reconciliation of Descrepancies in Medication histories and admission orders of newly hospitalized patients. Am J Health-Sys
Pharm., 2004, Aug. 15, Vol. 61.
6 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

External Support for the Process

There is widespread endorsement for a medication reconciliation process by healthcare quality and safety leaders and
regulators.
The Agency for Healthcare Research and Quality (AHRQ) was directed by legislation from Congress to produce
an annual report, the National Healthcare Quality Report, on healthcare quality in the United States. The 2004 report
includes in its prescribing medications measure, “Percent of adults who report that usual source of care [providers] ask
about prescription medications and treatments from other providers.” The emphasis is to have providers solicit informa-
tion concerning medication history from patients.
The Institute for Healthcare Improvement (IHI), a private leader in the promotion of healthcare safety and quality,
has endorsed medication reconciliation. The IHI included Prevention of ADE - Medication Reconciliation as one of the
six initiatives for its 100,000 Lives Campaign.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added medication reconciliation to
the 2006 National Patient Safety Goals (NPSG). These goals are determined annually by the JCAHO Sentinel Event
Advisory Group with recommendations from hospitals. They are top priorities for the prevention of adverse drug events
and the promotion of safety in healthcare.
According to JCAHO's 2006 NPSG, medication reconciliation should be done whenever the organization refers
or transfers a patient to another setting, other services, practitioner or level of care within or outside an organization.
At a minimum, medication reconciliation should be done any time the organization requires that the orders be rewrit-
ten. Orders may be rewritten when the patient is post-operative or changes service setting, provider or level of care.

JCAHO 2006 NPSG

GOAL #8 - Accurately and completely reconcile medications across the continuum of care.

• Implement a process for obtaining and documenting a complete list of the patient's current medications upon the
patient's admission to the organization and with the involvement of the patient. This process includes a comparison
of the medications the organization provides to those on the list.
• A complete list of the patient's medications is communicated to the next provider of service when a patient is referred
or transferred to another setting, service, practitioner or level of care within or outside the organization.

JCAHO suggests developing a medication reconciliation form to be used as a template for gathering information about
current medications as a method to standardize care and prevent errors.10 JCAHO's full list of medications included in
the reconciliation process are listed below.

JCAHO List of Medications to Reconcile11

1. Prescription Medications 8. Radioactive materials

2. Sample Medications 9. Respiratory therapy-related medications
3. Vitamins 10. Parenteral nutrition
4. Nutriceuticals 11. Blood derivatives
5. Over-the-counter drugs 12. Intravenous solutions (plain or with additives)
6. Vaccines 13. Any product designated by the FDA as a drug
7. Diagnostic and contrast agents

Introduction Tool
o Medication Reconciliation at Transition Points

9. Joint Commission on Accreditation of Healthcare Organizations, 2006 Edition Workbook. Improving Health Care Quality and Safety Hospital
Update. First Edition. Illinois: Joint Commission Resources. September 28 2005, Conference, Greensboro, NC. 134.
10, 11. Joint Commission on Accreditation of Healthcare Organizations, 2006 Edition Workbook. Improving Health Care Quality and Safety Hospital
Update. First Edition. Illinois: Joint Commission Resources. September 28, 2005, Greensboro, NC. 133-134, 159.
Medication Safety Reconciliation 7
8 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
2
A s s e s s m e n t
 Medication Safety Reconciliation 9

2
A s s e s s m e n t

Most who have attempted to implement a process to ensure medication reconciliation will agree that it is a journey. In
2006, American hospitals have embarked on this journey thanks to the Joint Commission on Accreditation of
Healthcare Organization's National Patient Safety Goals and to the Institute for Healthcare Improvement's 100,000
Lives Campaign,. Hospitals are finding that while the three-step process seems relatively straightforward and that it is
very beneficial for their patients, it is also very difficult to accomplish.
Hospitals are at different points in the journey. Some may have not started to implement the process, while others
may have implemented the process at one care transition point, but not at all care transition points. Still others may
have implemented at all three care transition points, but the process is not being done the way it was designed or it is
not consistently practiced with all patients.
A systematic assessment of medication reconciliation must be done to determine where your hospital is in the
process. In the case of an organization that has not implemented a process at all, it is important to assess your current
processes for medication history collection and determine if the physician orders and medication history are ever com-
pared, and if the discrepancies between these two lists are being resolved. An assessment will help you target your
improvement efforts and resources. It is important to have a more detailed understanding of the process in order to per-
form a systematic assessment.

Process Details
A systemic assessment requires a clear understanding of the process components and the sequence of the components.
The process components consist of medication history collection, comparing this list to the physician orders and resolv-
ing any discrepancies that may exist.

The medication reconciliation process is implemented in order:

1. the admission transition of care,
2. the transfer transition of care, and
3. the discharge transition of care.

Step 1 - Medication History Collection

Person obtaining history
A nurse, a pharmacist, a physician, a pharmacy technician or any combination of these may obtain the medication his-
tory. Some organizations use a team approach with a pharmacist and a nurse. Some organizations use a triage
approach, consulting a pharmacist to complete the medication history for patients that more than a specified number of
medications, or if they are on certain high risk medications or with specific diagnoses.

Sources of medication history

The medication history can be obtained from a variety of sources.
o The patient
o A list the patient may have
o The medications themselves, if brought in from home
o A friend or family member
o A medical record
o The patient's pharmacy
10 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

Process: (adapted from the IHI Getting Started Kit, updated 6/14/2006).
o Ask the patient if they have a medication list or if they brought in their home medications. If so, review the list with
the patient. Inquire about each medication, asking when and why they take it.
o If no list is available and the patient is able to provide the information, use a script to ask about medications. An
example script is available in tools and tips at the end of this chapter.
o If the patient is not able to provide this history, interview the patient's family member or friend or call the patient's
primary care physician or pharmacy.
o Review the patient's past medical record.

Suggest that the patient keep a list of all medications. Review this with the provider at each encounter with the hospital
admission or bring in their home medications at each visit. Some hospitals provide patients with prepared durable
bags for medications with the hospital logo printed on the side.

Documentation:
o Document the medication history including all the prescription medications, over the counter and herbal medica-
tions on the history form, see JCAHO list from Chapter 1 in this tool kit.
o Document for each medication dose, route, frequency, when was the last dose and why the patient is taking it.
o Place the medication list in a readily accessible, consistent location in the medical record.

Step 2 - Comparing Medication History & Orders

Person comparing the history:
Typically a nurse or a pharmacist compares the medication history and the physician orders.

Process:
o Comparison should note omissions, (a medication that appears on the history but not on the order and has no
documented reasons for discontinuation), or changes in dose, frequency or route.
o On admission, follow the steps above to collect the patient's history.

On transfer and discharge, you must use the medication history taken on admission and the current list of medica-
tions, often referred to as the medication administration record (MAR) and compare this to the physician orders.

Documentation:
Documentation should note if a discrepancy exists and the type of discrepancy.

Step 3 - Resolving Discrepancies

Person resolving discrepancy:
Typically a nurse or a pharmacist will notify the physician who ordered the medication to resolve the discrepancy. It is
the physician's responsibility to resolve the discrepancy with an order or provide an explanation for the omission.

Process:
o The physician can be notified by phone, computer or page to resolve the discrepancies.

Documentation:
o Documentation to resolve the discrepancy will either be an explanation on the reconciliation form or in another
location designated in your chart or a new physician order.
 Medication Safety Reconciliation 11

Assessment

The individuals involved in the medication reconciliation process (admission, transfer, or discharge) can provide a gen-
eral understanding of how the steps of medication reconciliation are currently being carried out by using the Admission,
Transfer or Discharge Medication Reconciliation Process Flow Chart located at the end of this section. The information
source for the medication history, who records the information, where it is recorded, how the orders are written, who is
reconciling the medications, and who is addressing the discrepancies is contained on the Flow Chart(s). Even if your
organization has not yet implemented, it is a good idea to understand how processes are currently being done. To
collect this information in a simple way use the graphic flow charts at the end of this chapter. Give a flow chart to a
sample of nursing staff, pharmacists and physicians on your floor. Ask them to map out your current process as they
practice and understand it by circling an item in each column and connecting the circles with a line. This will provide
you a quick way to gather information and direct you to the next step of assessment.
In the final step of assessment, randomly select 10 - 20 charts and walk through the Medication Reconciliation
Assessment Algorithm. Ask yourself if there is evidence (documentation) of reconciliation and if it is being done as it
was intended.

Other Tips and Tricks

Learning from others who have implemented medication reconciliation is helpful for identifying potential barriers and
strategies to overcome those barriers. At the end of this section, see the IHI Tips and Tricks as a reference for these
“lessons learned.”

Assessment Tools & Tips

o Medication History Scripting & Tips for Collecting Guidelines (OSF)
o Admission Medication Reconciliation Process Map
o Transfer Medication Reconciliation Process Map
o Discharge Medication Reconciliation Process Map
o Medication Reconciliation Process Assessment Algorithm
o Unit Medication Reconciliation Evaluation Form
o IHI Tips and Tricks (IHI Getting Started Kit, v2.01, June 2006)
12 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 13
14 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 15
16 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 17
18 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 19
20 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 21
22 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
3
T h e P ro j e c t
 Medication Safety Reconciliation 23

3
T h e P ro j e c t

Before you begin a performance improvement project, it is important to understand the basic tasks involved and decide
who will manage the project. While a dedicated project team, including the direct care providers, is desirable to con-
duct the performance improvement project, the resources are not always available to do this. The team leader initially
may need to devote more time than other members of the team to facilitate the project. Additionally, it is important to
estimate resource consumption of other team members to ensure the clear expectations of time commitments. This chap-
ter is designed to guide you through the planning stage.

Manage your project

Two of the most important elements of an effective project are a clear plan to determine resources required and a
realistic schedule. You may want to ask yourself the following questions:
1) How many resources are available to conduct this project?
2) Who within the hospital is available to work on this project?
3) When do I need to have the medication reconciliation process in place?

Before you decide on a budget and the project's scope, we recommend that you read this entire Tool Kit since it out-
lines the tasks that need to be accomplished.

Your project plan is unique to your facility. It is dependent on where and how you receive your customers. It is also
dependent on your current systems, size, culture and adaptability. All these factors determine the number of tests of
change and how quickly the plan can be implemented. In the first six weeks of the project, you will understand your
current process, develop ideas to change or create a new process, and perform two tests of change. The timeline
below is a guideline to help plan the tasks that will need to be completed.
24 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

Form a project team and schedule regular meetings

Who are the best people to work on the project team? The project team is vital to the success of your project. An
effective team will include representatives from every phase of the process, including nurses, pharmacists and physi-
cians. To ensure that the process can spread successfully in your organization, it is also important to include represen-
tation from quality improvement or another administrative professional that will address the organization as a whole. In
addition to having diverse professionals on your team, you will want to identify the roles of the team members. This
may be based on their skills inventories. Successful project teams have identified roles, such as a team leader or facili-
tator, a recorder and a meeting time keeper. Additionally, you may choose to assign a task based on profession or
duties. At the end of this chapter, there are tools to help with recording skills inventories and assigning team roles and
tasks.

The project team's responsibilities

The project team is responsible for a variety of duties. Highlights of some of these project duties include:
o Planning - Determining the scope of the project based on available resources and planning project tasks
o Selecting the Project Location and Communication - Determining where the pilot or test project will be done, gath-
ering of initial baseline information, how the project will be communicated and who will be responsible for the
communication that is carried out
o Selecting and Testing Change Ideas- Reviewing the data, making recommendations for process changes and
assuring that the changes are tested effectively
o Collecting Data - Assigning responsibility to individual(s) for data collection
o Spreading New Process - Developing spread plan, including education and communication
o Formalizing Process - Assigning responsibility to an individual(s) to formalize process in the organization

Team Meetings
The project team meetings should be considered sacred time and used as a time to brainstorm, discuss findings and
determine a common direction. Some teams choose to do meetings electronically or over the telephone. Regardless of
how you decide to conduct your regularly scheduled team meetings, you should use agreed-upon ground rules.

Communication and Engaging Others

Communication, early and frequently, is essential to the success of any quality improvement project. Communication
will need to include education on the problem and the solution, and must target a specific audience.

Engage Leadership
Leadership is paramount in setting and communicating the vision for the entire organization. John P. Kotter, a well-
known author and Harvard business professor, wrote in his book Leading Change that “Leadership should estimate how
much communication of the vision is needed, and then multiply that effort by a factor of ten” (Kotter, 1996). Therefore,
early engagement of senior administrative and physician leadership is one of the most important determinants for proj-
ect success.
The methods of communication and education can be verbal and or written and should be targeted to the admin-
istrative audience. It should convey a concise message outlining the cost of the problem (medication errors) and the
solution (medication reconciliation). When examining costs and benefits it is important to keep in mind the four sectors
of the hospital's business: financial, customer, learning and growth (employee development), and the internal business
(mission, service or product). While all four quadrants of the hospital business are important from the leadership per-
spective, they may have a greater perceived obligation to the financial aspects of the hospital business. Therefore,
your message should be delivered with great emphasis on financial costs. Tools at the end of this chapter can assist
you in communicating the message to the senior leadership.
The financial costs of placing a medication reconciliation process in place can be broken down into two parts.
The first part is the project costs. These are the costs associated with establishing a team, running pilot projects to test
and tweak the process, educating the various stakeholders, purchasing items that you may need to run the pilots and
 Medication Safety Reconciliation 25

later, spreading and formalizing the process so it is incorporated into routine operations.. This tool kit will offers a sam-
ple white paper proposal to help you estimate project costs. It does not address operational costs. These costs are
beyond the scope of the tool kit and vary greatly depending on your organization.
The second part of the financial costs associated with establishment of a medication reconciliation process at each
care transition point is the costs of on-going operations. To determine these costs, you must have an understanding of
who will be responsible for each step of the process, how much time each step will require. It is important to note that
many hospitals have placed the medication reconciliation process into routine operations without any additional staff.
To do so these organizations have carefully assessed their current processes, eliminated steps (for example a medica-
tion history in an admission assessment located elsewhere in the medical record) that are no longer needed and been
very creative in addressing their barriers. Creative ideas such as using a consulting pharmacist for specified criteria,
redistributing workload of team members to accomplish, etc. You can hypothesize what this may look like for your hos-
pital based on similar hospitals strategies and added costs.
To balance expenditure, it is necessary to examine the benefits. The data collected in this project can assist you.
Also, identifying the rate of ADEs prior to the implementation and then a year after the implementation. Additionally,
you can examine the length of stay associated with ADEs. The financial costs can then be estimated. Some may
argue that tying these indicators to financial costs is a stretch. However, the financial cost of care will be reduced if
your process allows you to deliver better, more efficient and safer care. Until your team collects data for several
months, however, documenting the benefits may be difficult. In the meantime, you may project the benefits by applying
your hospital's financial data to outcomes in published studies. (See the reference section in Chapter 1 - Introduction).

Engage Physicians
Many physicians shutter at the term medication reconciliation. They have been asked to change their processes and
sometimes adopt new ones that seem far too complex. The process should be designed to reduce their workload,
eliminate steps if possible and fit into the regular workflow (IHI Getting Started Kit v2.01). As with senior leadership
engagement, physician engagement is very important to the success of your project. If there is a physician leader that
is also a senior administrative leader that you previously engaged, it is recommended to ask her/him to champion this
effort. In any case, identifying one or more physician leaders - either formal leaders or respected “thought leaders” - to
champion the initiative will make your efforts much easier.
In targeting physicians, a concise message in many different formats and venues will be important. Most physi-
cians in today's environment are feeling overwhelmed. A message that conveys the importance of medication reconcili-
ation to the safety of their patients should be emphasized. It will be important to deliver a balanced message that
stresses that the aim of medication reconciliation is not to question their ability to order medications for their patients,
rather medication reconciliation is a safety net put in place to assure that the patient receives exactly the medications
that they need. Assure the physicians that they are a very important part of this safety process for the care of their
patients.
Sharing the outcome data, such as the percent of admissions (or transfers, or discharges) with any unreconcilied
medications, percent of unreconciled medications or unreconcilied medications per 100 admissions (or transfers or dis-
charges) can assist you in helping build the case for medication reconciliation. Until your hospital data is available,
you may need to share study data with the physicians. But perhaps the most effective and inspiring way to evoke
change it to share the individual stories of patients with the physicians. The physician is the key player in this initiative
and therefore must be involved in developing a process that works.

Engage Staff
As with educating the senior leadership and physicians, communication with the staff is very important. The staff, like
the physicians, will need to participate in process development. They are the keys to the success of the team, as they
will more than likely be involved in either the collection of the history or in the comparing and notifying the physician of
discrepancies. A clear understanding of the purpose of medication reconciliation and their contribution to the process
is very important.
In targeting the message to staff you will need to keep in mind that they, like physicians, are inundated with tasks
26 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

and responsibilities. Asking them to learn about a new program, let alone participate in a pilot project or development
of the process, may seem too much for some. Therefore, the message to the staff will place a great emphasis on the
enhancement of their work environment and care and service delivered to their patients. It will be important to deliver
a balanced message that stresses the aim of medication reconciliation is not to question the care that she/he has been
delivering, or to take over her/his responsibilities to safe medication administration, but rather to put a safety net in
place to deliver the right medication to the patient every time.
It is also important to communicate to the staff that while this may seem like more time on the forefront, medication
reconciliation has actually saved time with errors and complications later on in a patient's admission.
Studies can be shared with this group until outcome data becomes available. Once the outcome data (such as
the percent of admissions (or transfers, or discharges) with any unreconcilied medications, unreconcilied medications
per 100 admissions (or transfers or discharges) and percent of unreconciled medications) becomes available, even in
the pilot group, it should be shared with all staff members. Printing your online run charts will assist you as you commu-
nicate your progress during the project. As with physicians, sharing specific patient examples (stories) can be a very
powerful motivator.

Engage and Educate the Patients and Families

Patients can and should play a major role in the medication reconciliation process. As the only constant player in the
process, the patients have the ability to ensure that their list is updated with every visit to their providers. Education and
communication with patients and families will need to explain the purpose of medication reconciliation and their role in
the process. There are many examples of medication lists and wallet cards that are being used. There is a copy of
one from OSF Saint Francis Medical Center and one that has been developed and endorsed by the North Carolina
Medical Society in the back of this chapter.

Frequent Ongoing Communication with All Audiences

To effectively lead change, we must communicate our message again and again and again. We may start to think that
everyone already knows what we are going to say because we have shared it so many times before. According to
Kotter in Leading Change “The most carefully crafted messages rarely sink deeply into the recipient's consciousness
after only one pronouncement. Our minds are too cluttered and any communication has to fight hundreds of other
ideas for attention…effective information transferal almost always relies on repetition.” (Kotter, 1996). Communication
informs all audiences of why the effort is important and invites participation. Common communication methods are
newsletters, posters in common areas, staff meeting agenda items, and face-to-face meetings. There are examples of a
communication newsletter, poster and a communication checklist at the end of this chapter. Additionally, there is a
power point slide presentation to help communicate your message. The presentation can be adapted to a specific
audience (leadership, physicians, pharmacy/nursing staff) by removing or revising slides.

The Project Tools

o Medication Reconciliation Proposal for Hospital Leadership (management tool)
o Form a Project Team (management tool)
o Team Meeting Form (management tool)
o Communication Checklist (communication tool)
o Communication Flyer (communication tool)
o Communication Newsletter (communication tool)
o Medication Reconciliation Presentation (communication/education tool)
Medication Safety Reconciliation 27
Resources:
Proposed Project Expenses
Direct Expenses – Personnel
Project Personnel Project Total Number of Total Number of Total Personnel Projected
Role Hours Hours Project Cost Total
(Weeks # 1–6 of (Weeks # 7–27 of Hours (Cost/Hour) Project
Project) Project) Direct
Costs
(Personnel)
A B A+B=C D CXD= E
Performance Improvement Professional Project 60 152
Week 1-6 = 10 hours per week Manager
Week 7-26= 8 hours per week
Physician Champion Team
Week 1-6 = ____ hours per week Member
Week 7-26= ____ hours per week
Staff Nurse Team
Week 1-6 = ____ hours per week Member
Week 7-26= ____ hours per week
Nurse Manager Team
Week 1-6 = ____ hours per week Member
Week 7-26= ____ hours per week
Pharmacist Team
Week 1-6 = ____ hours per week Member
Week 7-26= ____ hours per week
Information Support (IS) Team
Week 1-6 = ____ hours per week Member
Week 7-26= ____ hours per week

Proposed Project Expenses (continued)

Direct Expenses - Non-personnel
Item Number of Items Cost per Item Projected
Total Project
Direct Costs
(Personnel)
A B AxB=C
Forms
Office Supplies
Posters
Medication Safety Reconciliation 29
30 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 31
32 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 33
34 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 35
36 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 37
38 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 39
40 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 41
42 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 43
44 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 45
46 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 47
48 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 49
50 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
4
P e r f o r m a n c e
I m p ro v e m e n t
 Medication Safety Reconciliation 51

4
P e r f o r m a n c e I m p ro v e m e n t

You have now read about the problem (adverse drug events), the solution (medication reconciliation), medication recon-
ciliation process specific details, communication strategies and planning and managing your project. It is now time for
the project team to determine the unit or floor to start the performance improvement project. The unit or floor can be
determined by your assessment, some baseline data collection, and/or by the receptiveness of the unit/floor staff to
change.
The Model for Improvement was first published in 1992 by Langley, Nolan, et al, in “The Improvement Guide: A
Practical Approach to Enhancing Organizational Performance.” This model provides a framework for developing, test-
ing and implementing changes in the way we do things. It is a simple approach that is highly effective and reduces the
risk associated with changing something we do by utilizing small tests of change. The model is also referred to as
rapid cycle of change.

The model consists of two parts the “thinking” part and the “doing” part.

The “thinking” part consists of three questions:

1. What are we trying to accomplish? (GOAL)
2. How we will know that change is an improvement? (DATA)
3. What changes can we make that will result in improvement? (DO SOMETHING DIFFERENT)

What are we trying to accomplish? GOAL

The goal should be specific and measurable; for example, reduce the number of unreconciled medications at transfer
by 25% in the next two months. After setting the goal, you will review and clarify the current processes and decide
which test population to use to initiate the test cycle. For example, this could be the next 5 to 10 patients admitted to
the pre-selected floor, or maybe the next 5 to 10 patients of Dr. Smith. Additionally, you will need to assign responsi-
bility for facilitating the test of change, evaluating the test of change and reviewing the charts to gather data on the
changes.

Are we making a difference? DATA

To understand if you are making an improvement it is necessary to collect data. Data includes chart audits and infor-
mation obtained from those that were involved in the “doing” part or the PDSA. At the end of this chapter, there is a
detail data section that will explain the data we are collecting for this project.

What are the possible ideas for change? DO SOMETHING DIFFERENT

By brainstorming, the team will determine possible change ideas to eliminate medication discrepancies between the
medication histories and current medication list and the admission, transfer or discharge orders. One change idea to
test will be identified. The detailed plan for the test, including the day, time, the location and the people involved, will
be planned.
The second part of the model for improvement, the “doing” part, consists of four components, plan, do, study, act,
or PDSA. We refer to these cycles as test cycles.
52 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

Plan
The plan should include the objective, any predictions, the plan to carry out the cycle (who, what, where, when) and
the plan for data collection. Data collection will be discussed in detail at the end of this chapter. The detailed plan for
the test of change should be shared with all involved in the process and the plan will be executed.

Do
This is actually carrying out the plan, documenting the observations and recording the data. Obtaining feedback from
all involved in the test of change will determine the success of the new process (elimination of discrepancies) or if addi-
tional tests of change need to be explored.

Study
Analyze the data by comparing it to the predictions and summarize what was learned.

Act
You will want to re-run the test of change with a new or modified change idea if the evaluation of your first test of
change reveals problems. These tests may need to be re-run more than once as you improve your process to eliminate
discrepancies between the medication histories or current lists and the admission, transfer or discharge orders. Once
you determine that your improved process is effective, the new process will need to be tested with an expanded popu-
lation. For example, expand the test beyond Dr. Smith's patients to all the patients admitted on the surgical floor.

Data Collection - Measuring Your Medication Reconciliation Success

You will need to measure data before you start your performance improvement cycles, baseline data, and then contin-
ue measuring as you refine the process with additional tests of change. This will help you understand the impact of
your changes and determine if additional changes are needed.
Measuring your medication reconciliation success requires a review of charts to identify discrepancies.
Discrepancies in medication orders between the outpatient and inpatient settings and the admission orders, between
the medication history and current medication list and the intra-hospital transfer orders, or between the medication histo-
ry and current medication list and the discharge orders, need to be measured. A clear definition of a discrepancy or
unreconciled medications is necessary.

Unreconciled Medication or Medication Discrepancy

Compare the medication orders to any available information about the medication that the patient was taking. Any dis-
crepancies between the medication orders and the medication lists (history or MAR) should be included as an error.
Note some clinical judgment is required. For example, it is not an error if the patient is admitted for low blood sugar and
insulin orders are discontinued.

Data to Collect
The goal of your data collection is to be robust enough to demonstrate if improvements have been obtained, yet simple
enough to collect so it is not burdensome. Keeping this in mind, data points for this Tool Kit have been kept to a mini-
mum.
You will need to collect initial baseline data and on going data throughout the project. The data you will need to
collect each month are an identifier (the review number and the patient/record number), the total number of medica-
tions on the chart, the number of unreconciled medications, and if there was evidence of reconciliation. This data are
collected on a tally sheet located at the end of this section. Simple calculations are used to determine the process and
outcome measures. This project has been set up for you to enter your monthly tallies into a secure on-line data submit-
tal collection form that will automatically calculate your measures. Alternatively, after the completion of the project you
can tally your monthly data and then calculate the measures manually using the sheet at the end of this chapter.
 Medication Safety Reconciliation 53

Process Measure
Changes in processes are necessary to improve outcomes. The medication reconciliation process measure used in
this tool kit is the percent of admissions with documentation of reconciliation. The process measure can apply to the
other transition points such as transfer or discharge by collecting data for each of those processes.

PROCESS MEASURE
Percent of Total # of Records Reviewed with Evidence of Reconciliation
Reconciled = Total Number of Records Reviewed
Admissions
** Substitute Transfers, or Discharges for Admission depending on process that you are improving

Outcome Measures
You need to understand if the changes that you have made to your process are impacting the number of medica-
tions reconciled at transition points. To do so, you will need to collect and analyze outcome data. There are three dif-
ferent outcome measures that you will collect: percent of unreconciled medications, unreconciled medications per 100
admissions, and percent of admissions with unreconciled medications. Again, these outcome measures can be altered
to address the different transition points by substituting transfer or discharge for admission.

OUTCOME MEASURES
1.) Percent of Number of Unreconciled Medications on Reviewed Records
Unreconciled = Total Number of Medications on Reviewed Records
Medications

2.) Percent of Admissions**

with Any = Total Number of Records Reviewed with any Unreconciled Medications
Unreconciled Total Number of Records Reviewed
Medications

3.) Unreconciled
Medications per = Number of Unreconciled Medications on Reviewed Records X100
100 Admissions** Total Number of Records Reviewed
** Substitute Transfers, or Discharges for Admission depending on process that you are improving

Performance Improvement Tools

o PDSA Worksheet (performance improvement)
o Medication Reconciliation Data Collection Form (data collection)
o Medication Reconciliation Measure Calculation Form (data collection)
54 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 55
56 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
5
S p r e a d a n d
F o r m a l i z e
 Medication Safety Reconciliation 57

5
S p r e a d a n d F o r m a l i z e

Spreading and formalizing your changes is an important part of implementation of a new process. It is necessary to
achieve an overall improvement with medication reconciliation. Medication reconciliation cannot be done in isolation.
As your patient flows through your hospital, the reconciliation that occurred on admission will be used in transfer
reconciliation and, likewise, in discharge reconciliation. To achieve successful communication of the patient's medica-
tions at transition points, it is necessary to spread the process throughout the organization. To ensure consistency, it is
necessary to formalize the process.

Spreading
After you have made changes to your process and tested and measured the changes to ensure improvements have
yielded an increase in reconciled medications, you are ready to spread your refined process.
Spreading your process to different areas of the hospital will require a plan. The project team should decide the
order in which to spread, who will be responsible for the spread, and the actual dates/times for implementation.
Spread should occur on similar units first. As you introduce the process to the new unit or floor, you will need to edu-
cate the staff and solicit feedback. Below is an example of a typical hospital spread plan.

As you introduce the process to the new unit or floor, you will need to educate the staff and solicit feedback. At the
end of this chapter, the Spread Process Checklist and Medication Reconciliation Process Inventory will assist you with
planning your spread.
58 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

Formalizing
The final step to ensure that your process will be consistently and widely used is to write or
revise your existing policies and procedures and removing all evidence of old processes. Your processes should outline
the medication reconciliation process in your organization and the roles and responsibilities of staff. You will also need
to provide on going education of the process for new members of the staff and hold existing staff accountable for the
new process by incorporating this into yearly competency training and performance evaluations. Lastly, you will need
to continue to monitor the effectiveness of the new process. These steps will assist you in formalizing your process. At
the end of this section there is an example of a Formalizing the Process Checklist and Medication Reconciliation
Procedure(s).

Communicate Project to Others

Spreading
o Meet with leadership and medical executive committee
o Meet with departments affected the most
o Send newsletters, post posters
Formalizing
o Post permanent reminders of the new process
o Communicate success of the new process

Spreading and Formalizing Changes Tools

o Spreading Checklist
o Hospital Implementation Plan Worksheet
o Formalizing Checklist
o Example Procedure for Documentation Form
o Example Documentation Form
o Example Procedure for Order Form
o Example Order Form
o Patient Health Snapshot (Patient Care Card)
Medication Safety Reconciliation 59
60 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 61
62 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 63
64 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 65
66 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 67
68 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 69
70 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 71
72 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 73
74 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
6
R e f e r e n c e
M a t e r i a l s
 Medication Safety Reconciliation 75

6
R e f e r e n c e M a t e r i a l s

Medication Reconciliation

Barnsteiner JH. Medication Reconciliation: Transfer of medication information across settings-keeping it free from error.
Am J Nurs. Mar 2005; 105(3 Suppl):31-6. No abstract available. PMID: 15802996 [PubMed - in process].

Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medica-
tion histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. Aug 2004;
15;61(16):1689-95. No abstract available. PMID: 15540481 [PubMed - indexed for MEDLINE]

Institute for Safe Medication Practices. Use your pre-admission process to enhance safety. ISMP Medication Safety
Alert! October 30, 2002; p.2.

Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health-Sys Pharm.
October 1, 2003; 60:1982-6. Early version appeared under title “Use of Pharmacy Technicians to Reconcile Patients'
Home Medications” as Am J Health-Sys Pharm Best Practice Awards. 2002. www.ashpadvantage.com/bestprac-
tices/2002_papers/michels.htm.

Pronovost P, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of Critical
Care. Dec 2003;18(4):201-205.

Rozich JD, Resar RK, et al. Standardization as a mechanism to improve safety in health care: impact of sliding scale
insulin protocol and reconciliation of medications initiatives. Joint Commission Journal on Quality and Safety;30(1):Jan
2004; 5-14.

Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication reconciliation in the acute care setting:
opportunity and challenge for nursing. J Nurs Care Qual. Apr-Jun 2005; 20(2):95-8. No abstract available. PMID:
15839287 [PubMed - in process].

Whittington J, Cohen H. OSF Healthcare's journey in patient safety. Quality Management in Health Care. Jan-Mar
2004;13(1):53-9.

Adverse Drug Events and Medication Errors

AHRQ. Reducing and preventing adverse drug events to decrease hospital costs. Research in Action, Issue 1. AHRQ
Publication Number 01-0020, March 2001. www.ahrq.gov/qual/aderia/aderia.htm.

Bates DW, Spel N, Cullen DJ, etal. The costs of adverse drug events in hospitalized patients. Adverse drug events pre-
vention group. JAMA 1997;277:307-311.

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potentially adverse drug events. JAMA
1995;274:29-34.
76 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

Beers MH, Sliwkowski J, Brooks J. Compliance with medication orders among elderly after hospital discharge. Hosp
Formul 1992;27:720-724.

Beers MH. Explicit criteria for determining potentially inappropriate medication use in the elderly: an update. Arch
Intern Med 1997;157:1531-36.

Billman G. Medication coordination for children with cancer (Children's Hospital - San Diego). Presentation at AAP
Patient Safety Summit. May 21, 2002.

Classen DC, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mor-
tality. JAMA 227:301-306, 1997.

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and severity of adverse events affecting patients
after discharge from the hospital. Annals of Internal Medicine. February 4, 2003; 138(3):161-167, E168-174.

Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:29-34.

Kanjanarat P, Winterstein AG, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J
Health-Sys Pharm. 2003;60(14):1750-1759.

Muir AJ, Sanders LL, et al. Reducing medication regiment complexity: a controlled trial. Journal of General Internal
Medicine. Feb. 2001;16:77-82.

Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health-
Sys Pharm. 2002;59(22):2221-2225.

Scott BE, et al. Pharmacy-nursing shared vision for safe medication use in hospitals: executive session summary. Am J
Health-Sys Pharm. 2003;60(May 15):1046-52. www.ashp.org/public/pubs/ajhpopen/5b-sf-Thompson.pdf.

U.S. Pharmacopeia. Miscommunication leads to confusion and errors: cause of errors, case illustration, and suggestions
to minimize errors in communication. USP Patient Safety CAPSLink Newsletter, December 2003. See also other issues
analyzing errors submitted to their medication error database.

Website Resources

Agency for Healthcare Research and Quality (AHRQ)

www.ahrq.gov/qual/errorsix.htm

American Society of Health-System Pharmacists

www.ashp.org

The Carolinas Center for Medical Excellence

www.thecarolinascenter.org

Institute for Healthcare Improvement (IHI)

www.ihi.org

Institute for Safe Medication Practices

www.ismp.org
 Medication Safety Reconciliation 77

Massachusetts Coalition for the Prevention of Medical Errors

www.macoalition.org

National Patient Safety Foundation

www.npsf.org

Pathways for Medication Safety

www.medpathways.INFO

US Pharmacopeia (CAPS, MedMarx)

www.usp.org

Examples
Medication Reconciliation Policies/Procedures and Forms (see attached pages)

Caritas Norwood Hospital. Medication Reconciliation Form. Retrieved September 25, 2006 from Massachusetts
Coalition for the Prevention of Medical Errors website at
http://www.macoalition.org/Initiatives/RecMeds/CaritasNorwoodReconcilForm.doc.

Example Hospital Policies. Retrieved September 25, 2006 from Massachusetts Coalition for the Prevention of Medical
Errors website at
http://www.macoalition.org/Initiatives/RecMeds/ExamplePolicies.pdf.

UMassMemorial. Preadmission Medication List Verification and Order Form (Medication Reconciliation). Retrieved
September 25, 2006 from Massachusetts Coalition for the Prevention of Medical Errors website at
http://www.macoalition.org/Initiatives/RecMeds/UMassReconcilForm.doc.
78 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 79
80 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 81
82 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 83
84 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 85
86 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 87
88 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 89
90 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 91
92 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 93
94 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 95
96 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 97
98 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety
Medication Safety Reconciliation 99
100 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

IHI Mentor Hospitals - Medication Reconciliation

Buena Vista Regional Medical Center - Storm Lake, IA
Availability Status: Available to answer requests
Licensed Beds: 54
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Rural
Start Date of Intervention Work: November 2004
Mentor Contact Name: Michele Kelly, RNC, MSN, Dir. of Quality
Mentor Contact Email: kelly.michele@bvrmc.org
Mentor Contact Phone: 712-213-8604

Additional Information:

*Developed and implemented medication reconciliation process throughout all inpatient areas. Currently working on
expansion to outpatient care areas.
*Process includes use of standardized medication reconciliation documentation form that is initiated within 8 hours of
hospital admission, updated throughout hospitalization, and again at the time of discharge.
*Process includes gathering patient medication history, verification of history, and reconciliation with medications
ordered at time of admission, transfer and discharge.
*Medication Reconciliation Policy developed to describe guidelines for use of documentation tool.

Process: As of March 2006, current data shows 99% compliance with use of Medication Reconciliation Tool for inpa-
tients on pilot unit (Med-Surg). Baseline data from 10/2004 (prior to implementation)--0% compliance as no process for
medication reconciliation existed.
Outcome: Data for Medication Variances for calendar year 2005 show no adverse drug events related to medication
reconciliation process.

* * *
Columbus Regional Hospital - Columbus, IN
Availability Status: Available to answer requests
Licensed Beds: 325
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Rural
Start Date of Intervention Work: July 2002
Mentor Contact Name: Mary Sitterding
Mentor Contact Email: msitterdin@crh.org
Mentor Contact Phone: 812-376-5474

Additional Information:

Columbus Regional Hospital has adopted medication reconciliation as a key strategy in alignment with our organiza-
tional priority to keep patient's safe. The Medication Reconciliation Team thrived within a culture that embraces the
combination of rapid cycle testing, LEAN, and a complex adaptive systems approach to problem identification, solution
generation and testing. Principles of complex adaptive systems as they relate to medication reconciliation are illustrated
through structure, process, and pattern cycle changes. Innovative collaboration between IT and the Interdisciplinary
Improvement Team resulted in an automated solution that dramatically reduced the number of steps required for medica-
tion reconciliation as well as the need for transcription. The team learned that standardizing forms, personal check
lists, working harder next time, feedback of information, and awareness and training (Reser, 2003) will only allow a
team to move so far. Steps implemented by the team that got us a little close to Level 2 (Reser, 2003) included: build-
ing decision aids and reminders into the system, redundancy, taking advantage of habits and patterns, and standardi-
zation of the process.

Admission Reconciliation Accuracy

1. Pilot nursing unit: 59 unreconciled medications/1140 medications reviewed (5% unreconciled/ 95% accuracy)
2. Hospital wide nursing units: 562 unreconciled medications/4078 medications reviewed (13% unreconciled/87%
accuracy.
 Medication Safety Reconciliation 101

IHI Mentor Hospitals - Medication Reconciliation

Discharge Reconciliation Accuracy
1. Pilot Nursing Unit - 100% accuracy
2. Hospital Wide nursing units - 88% accuracy

Community Hospital North - Indianapolis, IN

Availability Status: Available to answer requests
Licensed Beds: 629
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: September 2005
Mentor Contact Name: Cleo Ann Burgard
Mentor Contact Email: cburgard@ecommunity.com
Mentor Contact Phone: (317) 621 5329

Additional Information:

This intervention is spread throughout our five (5) Network hospitals: Community Hospital Anderson, Community
Hospital East, Community Hospital North, Community Hospital South, and the Indiana Heart Hospital

o The Community Health Network utilized LEAN Methodology to focus on improvement opportunities involving med-
ication reconciliation
o Nursing satisfaction surveys conducted by pharmacy have noted a low level of dissatisfaction with their role in the
medication reconciliation process
o Utilization of pharmacists to augment the medication history process is widely accepted by nursing, physicians and
hospital administration to be essential to obtaining the most complete and accurate medication list at time of
admission
o Partnership with the IT department has resulted in the development of an electronic document linking the admission
home medication list to the current MAR facilitating discharge plans for patients
o Involving pharmacists in the medication reconciliation process has dramatically increased their clinical visibility and
expanded clinical services
o Serial nursing/pharmacy and physician surveys will be used to track satisfaction with the process changes involv-
ing medication reconciliation
o Pharmacy has completed more than 1000 medication histories and provided improved accuracy and complete-
ness in more than 85% of the histories as compared to the original record obtained
o Pharmacy has quantified that the average duration of time to complete a medication history is approximately 25
minutes
o Process redesign has resulted in more than 50% of the clinical pharmacist's day is spent with direct patient care
interactions

* * *

Contra Costa Regional Medical Center - Martinez, CA

Availability Status: Available to answer requests
Licensed Beds: 164
Teaching / Non-Teaching Status: Teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: August 2005
Mentor Contact Name: Steven Tremain, MD
Mentor Contact Email: stremain@hsd.cccounty.us
Mentor Contact Phone: 925-370-5122

Additional Information:

After testing on a pilot unit, we successfully rolled out medication reconciliation on admission to all 11 inpatient units
within 5 months. As of January 2006, all units are now doing medication reconciliation upon admission and on trans-
fer, as applicable. In addition, linkages have been formed with Ambulatory Care so that medication information is
communicated to the hospital in a standard way. Techniques that led to success included:
102 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

IHI Mentor Hospitals - Medication Reconciliation

o weekly 45-minute meetings that stayed on task;
o a physician champion;
o pilots followed by spread;
o adopting and adapting the Med Rec form from Missouri Valley Baptist Hospital;
o reducing work for the caregivers (one less form, not one more form!); and
o electronic generation of med rec/order form for all in-hospital transfers.

We have conducted pre- and post-implementation measurements to assess the impact medication reconciliation on
admission has had in our first three services to go live. Our goal was to reduce the percent of unreconciled medica-
tions by 50% within three months of roll-out and we have exceeded that goal. Statistics that follow illustrate the % of
unreconciled medications on admission (among patients who are admitted with a history of at home meds):

Medicine Service = 22% (pre) and 1% (post)

Surgery Service = 36% (pre) and 5% (post)
ICU/IMCU Service = 10% (pre) and 2% (post)

Cooley Dickinson Hospital - Northampton, MA

Availability Status: Available to answer requests
Licensed Beds: 125
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: August 2005
Mentor Contact Name: Donna Truesdell
Mentor Contact Email: donna_truesdell@cooley-dickinson.org
Mentor Contact Phone: 413-582-2220

Additional Information:

Cooley Dickinson Hospital is a hospital that does not have an electronic MAR or CPOE. Therefore, our process is
completely paper and pencil driven. An interdisciplinary team initiated the medication reconciliation process in August
of 2005 with the development of a process for reconciliation of medications at the time of transfer utilizing pharma-
cists.

We quickly identified the need for better lists of "home medications" when patients arrive for care. CDH created a wal-
let card for medication lists and medical history and offered it to the public through numerous public relations efforts.
We collaborated with physician practices in the region to also make cards available in office waiting areas and to
have them updated during provider visits.

Medication reconciliation is currently operational in all inpatient and outpatient service areas. We have found outpa-
tient areas (particularly the emergency department) to be more challenging and continue to fine-tune that process.

Chart audits have demonstrated 85% reconciliation of all medications including inpatient and outpatient episodes of
care. Issues with reconciliation are now more performance issues with specific individuals and some areas have
achieved 100% reconciliation of medications.
[7/25/06]
* * *

Fairview Health Services - Minneapolis, MN

Availability Status: Available to answer requests
Licensed Beds: Depending on the site, from 41 beds to 1,700
Teaching / Non-Teaching Status: one teaching, the rest non-teaching
Urban / Rural Status: Some rural and some urban
Start Date of Intervention Work: 01/2001
Mentor Contact Name: Steven Meisel
Mentor Contact Email: smeisel1@fairview.org
Mentor Contact Phone: 612-672-7061
 Medication Safety Reconciliation 103

IHI Mentor Hospitals - Medication Reconciliation

Additional Information:

Like most Campaign hospitals, Fairview is far from perfect in our reconciliation efforts. We have, however, creatively
used technology and technicians to achieve our successes. We

o Use our ambulatory EMR, our inpatient EMR, and our inpatient pharmacy system in different ways in different sites.
o Use pharmacy technicians in several different ways.
o Work with our competitor hospitals on integrating our technology so that when a patient shows up at an ER of one
site, and is a patient of a competing health system, a suitable abstract is available to the clinicians.
o Have successfully defined a business case for reconciliation which has allowed several of our sites to add staff for
our reconciliation efforts.

Depending on the specific site:

o % home meds addressed by MD increased from 60% to 85%

o % defects/patient reduced from 1.7 to 0.2 in scheduled surgery patients
o reconciliation on transfer out of ICU increased from 40% to 96%
o admission reconciliation performed increased from 77% to 100%
o % of unreconciled meds on admission reduced from 48% to 7%
o admission reconciliation performed increased from 34% to 56%
o % meds reconciled on discharge increased from 50% to 80%
[1/31/06]

* * *

Frederick Memorial Hospital - Frederick, MD

Availability Status: Available to answer requests
Licensed Beds: 224
Teaching / Non-Teaching Status: Non-Teaching
Urban / Rural Status: Rural
Start Date of Intervention Work: June 2005
Mentor Contact Name: Cindy Russell
Mentor Contact Email: crussell@fmh.org
Mentor Contact Phone: 240-566-3326

Additional Information:

o As part of the ICU Collaborative, Frederick Memorial Hospital successfully implemented Medication Reconciliation
in the ICU on all patients that changed levels of care within the ICU or were transferred out to another level of
care.
o The model was so successful that it was rolled out to our admission center so that all admitted patients would have
Medication Reconciliation performed on admission. This represented 80% of all hospital admissions.
o The model is now being adopted in our same day surgical area.
o The model incorporates the prescribing/re-ordering activity by physician, which is valued highly by our physicians.
o Our process was received very favorably during our most recent JCAHO review in July 2005.
o Our process has been received well by nursing due to our method of incorporating the procedure into existing
nursing workflow.
o 0.2% Unreconciled Medication upon admission to the hospital through the admission center or Same Day Surgical
suite.
o 0% Unreconciled Medication upon transfer from ICU Level of care, since the inception of Medication reconciliation
in June 2005.

* * *
104 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

IHI Mentor Hospitals - Medication Reconciliation

Holy Spirit Hospital - Camp Hill, PA
Availability Status: Available to answer requests
Licensed Beds: 317
Teaching / Non-Teaching Status: Non-Teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: January 2006
Mentor Contact Name: Christina DeCoskey, RN, BSN (Medication Reconciliation Coordinator)
Mentor Contact Email: cdecoskey@hsh.org
Mentor Contact Phone: 717-763-2344

Additional Information:

Key reasons for our mediation reconciliation success:

o Our program provides support to our staff on this process.

o Multidisciplinary collaboration.
o We use a form that can be utilized as physician order sheet
o Our efforts have helped increase recognition of medication reconciliation as a patient safety concern.

Holy Spirit Hospital is a community hospital that currently works with a paper system. Our medication reconciliation
committee consists of members from nursing, pharmacy, physicians, education, and IT specialists. (We are in the
process of working on a computerized documentation system.) This initiative is fortunate to have a physician and nurse
champion who collaborate closely with our pharmacy and risk management departments.

Our program is unique in that we utilize a team of LPNs who are responsible for obtaining a medication list from
patients on admission. This team works directly under the Medication Reconciliation Coordinator (an RN) and is locat-
ed in the Pharmacy department. This arrangement has contributed to strong collaboration and more effective communi-
cation between departments.

Although getting buy-in from all the necessary stakeholders has at times been challenging, with a strong educational
effort and support from administration, we were able to implement this program on January 1st hospital-wide with good
success. Buy-in from some physicians is still sometimes a challenge, but our family practice and internal medicine physi-
cians have found the form we created to be a great reference and use it when they see patients.

Our medication reconciliation form is currently being utilized as an order sheet, but we are currently revisiting this
process with the different medicine and surgery departments. On discharge, we fax a reconciled list of medications to
patients' discharging physician or family physician.

Reduction in the percent of unreconciled medications on admission from 39% to 12-16% since January 2006.
Goal is to decrease the number of unreconciled medications on admission by 75% within 12 months.
[8/4/06]

* * *

Kossuth Regional Health Center - Algona, IA

Availability Status: Available to answer requests
Licensed Beds: 25
Teaching / Non-Teaching Status: Non-Teaching
Urban / Rural Status: Rural
Start Date of Intervention Work: January 2006
Mentor Contact Name: Dar Elbert, RN, MS - Assistant Administrator/Nurse Executive
Mentor Contact Email: elbertd@mercyhealth.com
Mentor Contact Phone: (515) 295-4601
 Medication Safety Reconciliation 105

IHI Mentor Hospitals - Medication Reconciliation

Additional Information:

o Kossuth Regional Health Center is a 25-bed Critical Access Hospital with two physician clinics, home care, hos-
pice, and public health.
o Kossuth Regional Health Center has been able to roll out the Medication Reconciliation process in the Inpatient unit
rapidly, as developed by our Network team through Mercy Medical Center - North Iowa, Mason City, Iowa.
o Within one day, we inserviced all inpatient nurses and providers and implemented the process beginning with all
new admits.
o Our Network used a form available on the IHI website and made slight adjustments to the tool, which is used to
reconcile medication orders on admission, discharge, change in level of care, and also serves as written orders
for discharge by the provider.
o We incorproated the tool into the discharge process and changed the discharge patient education forms to
include the addition of a medication wallet card, which they take to all appointments and medical care services
for continued updating.
o Added medication reconciliation tools and process to 100% of inpatient medical records. Baseline was 0% as no
process was in place for medication reconciliation.
o Outcome: no variances reported or discovered related to adverse drug events from lack of medication reconcilia-
tion process since implementation
[8/31/06]

* * *

Lynchburg General Hospital - Lynchburg, VA

Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: June 2005
Mentor Contact Name: Karen Douglas, RN, BSN, BC (Patient Safety Coordinator)
Mentor Contact Email: karen.douglas@Centra Health.com
Mentor Contact Phone: 434-947-7720

Additional Information:

o Joined the VHA Medication Reconciliation Collaborative in June of 2006 and participate in their coaching and
content calls
o Began with two units, a draft form and two nurses and added additional units and team members approximately
every two weeks until process rolled out to all inpatient and outpatient areas by February 2006. Worked with
Pharmacy to implement using form for ordering admission medications.
o Team members responsible for staff education and data collection. Sent bi-weekly reminders to collect data and
had drawings (to win $25.00 gift certificates) each month for those team members that turned in stats on time.
o To educate MDs, sent letters and put up education posters in MD bathrooms and lounges
o Enlisted Chief Medical Officer, a JD in health law, to answer questions that came up regarding legalities associat-
ed with the process.
o Met with team of surgeons, specialists, and nurses from outpatient areas to address special concerns re: outpatient
medication reconciliation and have developed separate form for outpatients/short stays
o Initiated public outreach with article in local paper March 7, 2006 regarding importance of maintaining current,
complete list of home medications to be given to healthcare providers when seeking care. Contacted Parrish
Nursing groups to spread the word in local churches.
o Baseline data demonstrated a rate 54.8% unreconciled medications on admission to Centra Hospitals. Goal is to
reduce rate by 75% or 13% unreconciled medications on admission.
o As of February 1, 2006, have reduced number of unreconciled medications on admission to 18%.

* * *
106 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

IHI Mentor Hospitals - Medication Reconciliation

Our Lady of Lourdes Memorial Hospital - Binghamton, NY
Availability Status: Available to answer requests
Licensed Beds: 267
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Rural
Start Date of Intervention Work: February 2005
Mentor Contact Name: Caryl Ann Mannino, RN, Director Professional Practice
Mentor Contact Email: cmannino@lourdes.com
Mentor Contact Phone: 607-798-5183

Additional Information:

Lourdes developed a process and policy for medication reconciliation on admission. After multiple tests of change, we
spread throughout the pilot unit. One week later, we spread to all inpatient units and the ED. Next, we successfully
spread to our Primary Care Network and Home Care service line. We are currently including patients who receive
services in the Ambulatory Surgery Unit. A structured educational plan was implemented that involved Nursing,
Pharmacy, and Medical Staff. The educational plan has been incorporated into nursing orientation.

Monthly chart reviews (a sample drawn from all inpatient units) demonstrated that we have had only 1 ADE since
September 2005. Unreconciled medications on admission have been reduced to 5% or lower since February 2005.
In November and December, the rate was 0% and 0.6%, respectively.
[1/31/06]

* * *
Prince William Hospital - Manassas, VA
Availability Status: Available to answer requests
Licensed Beds: 170
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: June 2005
Mentor Contact Name: June Lyda, Performance Improvement Manager
Mentor Contact Email: jlyda@pwhs.org
Mentor Contact Phone: (703) 369-8824

Additional Information:

Prince William Hospital implemented a pilot electronic medication reconciliation program in our Critical Care Unit. In
July 2005, the pilot was completed and analysis was such that this program was rolled out hospital-wide.

Interdisciplinary team formed with Physician as Leader, recent past president of the Medical Staff. Team Members
included Chief Pharmacist, Clinical Pharmacist, Information Systems Specialist, Clinical Manager of Information
Systems, Nurse Manager of Medical Floor, Intensive Care Unit Staff Nurse, Training & Development Nurse (education),
and Performance Improvement (PI) Manager. After the pilot project we added staff nurses from other settings (outpatient,
Birthing Center, Pre-operative surgery.)

PI Manager attended National IHI conference and focused on Medication Reconciliation. Informational articles and the
National Patient Safety Goal were sent to team members and a Power Point Education were presented to the team at
the first meeting.

Paper tools developed by other organizations (University of Massachusetts Memorial, Milford-Whitinsville Regional
Hospital) were researched. Information Systems personnel determined that an electronic order tool could be developed
through the existing software.
We piloted a small, restricted area and population of patients, the Intensive Care Unit (ICU) and those patients trans-
ferred out or discharged from the ICU. Multiple medications are frequently ordered as a patient is transferred from ICU.

In place of writing each medication, the physician can circle C=continue, M=Modify, or DC=stop the medication as it
is printed on a form which was eventually authorized as a physician order sheet. The physician signs as an order sheet
after circling the appropriate choice on each line item medication.
 Medication Safety Reconciliation 107

IHI Mentor Hospitals - Medication Reconciliation

The medication list is derived from the on-line Pharmacy profile for that individual patient and is up-to-date as per the
physician ordering. We did not have a paper tool to begin this process. Accurate information was obtained through
this pharmacy module profile. Time was saved on the part of the physician, Nurse and pharmacist with this tool as a
physician order.

During the pilot, use of the electronic medication reconciliation was voluntary, with a 50% usage. Of the cases utilizing
the program, there were 0% medication errors.
[5/12/06]
* * *
St. Luke's Hospital - Cedar Rapids, IA
Availability Status: Available to answer requests
Licensed Beds: 560
Teaching / Non-Teaching Status: Non-Teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: March 2003
Mentor Contact Name: Sherrie Justice
Mentor Contact Email: justicsl@crstlukes.com
Mentor Contact Phone: 319-369-8367 or 1-800-369-7217 ext. 8367

Additional Information:

o Developed a community-wide personal health record card. “Medication Matters” card is a small wallet-sized card
providing patients a way to document their medication. Program is supported by both community hospitals, all physi-
cian offices, the Cedar Rapids Health Care Alliance and local pharmacies.
o Developed and implemented medication reconciliation processes and electronic tools throughout all inpatient
areas. Includes use of standardized documentation forms that are utilized with every patient's transition in care from
admission to discharge.
o 150,000 “Medication Matters” cards distributed in the first year. Between both hospitals, continue to distribute
approximately 55,000 cards annually.
o As part of discharge process, nursing completes a “Medication Matters” card for their patient. One nursing unit
reports 95% compliance with this activity.
o Percentage of medications correctly reconciled at admission (May 2006) is 96% in the surgical population; 90%
in the medical population.
[8/31/06]
* * *
St. Peter Community Hospital - St. Peter, MN
Availability Status: Available to answer requests
Licensed Beds: 22
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Rural
Start Date of Intervention Work: March 2005
Mentor Contact Name: Benjamin W. Chaska, M.D., MBA, CPE, Medical Director and Patient Safety Officer
Mentor Contact Email: bchaska@stpeterhealth.org
Mentor Contact Phone: 507-934-8416

Additional Information:

Actions Taken
oDeveloped and implemented SPCH medication reconciliation form.
oRedesigned operational flow to incorporate medication reconciliation process into the medication intake, order sets,
transfer and discharge planning tools.

Results
oMedication reconciliation improved from 76% to 94.5%.
[1/31/06]

* * *
108 N o r t h C a ro l i n a C e n t e r for Hospital Quality and Patient Safety

IHI Mentor Hospitals - Medication Reconciliation

UMass Memorial Medical Center - Worcester, MA
Availability Status: Available to answer requests
Licensed Beds: 751
Teaching / Non-Teaching Status: Teaching
Urban / Rural Status: Urban
Start Date of Intervention Work: 4/03
Mentor Contact Name: Eric Alper, M.D.
Mentor Contact Email: AlperE@ummhc.org
Mentor Contact Phone: (508) 856-6431

Additional Information:

Our hospital has successfully deployed a medication reconciliation form and process. It is completed on admission
and reviewed on transfer and discharge. It is usually used as a physician order form for medication orders that should
be ordered on admission. This was deployed in a phased fashion through our hospital. Physicians and nursing have
received extensive education about this important process.

Through deploying this form and process, we have been able to implement this process in approximately 85% of our
hospital admissions. By performing retrospective chart reviews of medication reconciliation and adverse drug events,
(using the IHI trigger tool), we were able to demonstrate a substantial improvement in medication reconciliation (from
~50% baseline to 95-100%) over this period. We also observed a reduction in the frequency of adverse drug events,
from baseline of ~15% per 20 admissions to <5%.
[1/31/06]
 PO Box 4449, Cary, NC 27519-4449
Tel 919-677-2400 www.ncha.org/ncchqps