Medication Reconciliation
Case for Change
Preventable medication errors are associated with one out of five patient injuries or deaths. Estimates reveal that over 46% of all medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. A recent Institute of Medicine report estimated the extra medical cost of treating adverse drug events occurring in hospitals alone amounted to $3.5 billion a year. This estimate does not take into consideration lost wages and productivity or additional health care costs.
Medication reconciliation is a process designed to address this deficiency in the delivery of health care. Accurate and complete medication reconciliation can prevent:
- Inadvertent omission of needed home medications
- Failure to restart home medications following transfer and discharge
- Duplicate therapy at discharge
- Errors associated with orders with incorrect doses or dosages.
The reconciling process has been demonstrated to be a powerful strategy: Research showed that a series of interventions introduced over a seven month period successfully decreased the rate of medication errors by 70% and reduced adverse drug events by over 15%. In another study, the utilization of pharmacy technicians to initiate the pre-surgery reconciling process reduced potential adverse drug events by 80% within three months. In yet another case, an adult surgical intensive care unit implemented a medication reconciliation process to reduce medication errors in discharge order. By week 24 of the study, nearly all medication errors were eliminated.
A successful reconciling process also reduces time associated with the management of medication orders. A recent study showed that after implementation, nursing time at admission was reduced by over 20 minutes per patient. Furthermore, cases establish that initiating and following a systematic approach to medication reconciliation through the course of hospitalization reduces pharmacist time at discharge by over 40 minutes.
This tool kit will provide:
- Resources for planning and implementation
- Sample policies and procedures
- Iowa hospital medication reconciliation forms
- Provider and staff education materials
- Information regarding the IHC Med Card
Sources:
- 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.
- Pronovost P, et. Al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003 Dec;18(4):201-205.
- Rozich JD, Resar RK. Medication Safety: One Organization’s Approach to the Challenge. JCOM 2001; 8(10):27-34.
- Stencel, M “Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually.” The National Academies, July 20, 2006.
Tool Kit
Planning and Implementation
- IHI: How to Guide on Medication Reconciliation
- Massachusetts Coalition for the Prevention of Medical Errors Getting Started
- The following links provide some tips on getting started developed over the course of the Massachusetts Coalition for the Prevention of Medical Errors’ two-year Reconciling Medications Collaborative.
Additional Implementation Tools:
Additional Implementation Tools:
Policies and Procedures
Hospital Policies
- Buena Vista Regional Medical Center, Storm Lake, IA
Medication reconciliation policy implemented in a critical access hospital.
- Grinnell Regional Medical Center, Grinnell, IA
Guide to Reconciling Medications.
- Iowa Health System, Des Moines, IA
Current medication reconciliation policy developed by an interdisciplinary team representing inpatient, outpatient & ambulatory settings.
- Mercy Medical Center, Des Moines, IA
Current medication reconciliation policy addressing medication reconciliation upon admission, transfer, and discharge and guidelines for initial patient interviews.
- St. Luke's Hospital, Cedar Rapids, IA
Medication reconciliation policy addressing reconciliation upon admission, transfer within the facility, and discharge.
- Trinity Regional Medical Center, Fort Dodge, IA
Medication reconciliation policy addressing reconciliation upon admission, transfer within the facility, and discharge or transfer to another facility.
- University of Iowa Hospitals and Clinics, Iowa City, IA
An interdisciplinary procedure for conducting medication reconciliation in a large teaching facility.
- Luther Midelfort, Eau Claire, WI Medication Reconciliation and Discharge Medications Policy
An interdisciplinary procedure for conducting medication reconciliation within 24 hours of admission and at the time of discharge in order to generate an accurate medication list and thereby decrease adverse drug events.
- University of Massachusetts Memorial Medical Center, Worchester, MA
Preadmission Medication List Verification and Order Form Guidelines.
Example Process Flow Charts
- Luther Midelfort, Mayo Health System, Eau Claire, WI
Medication reconciliation reviews may be conducted during the admission process, often by nurses on the admission unit, to identify unreconciled medications and potential errors or adverse events. This flowsheet helps nursing personnel perform a medication reconciliation process when patients are admitted to an intermediate care unit, either directly or as transfers from other inpatient care units.
- University of Massachusetts Memorial Medical Center, Worchester, MA
Admission Medication Reconciliation Process for Elective Orthopedic and Emergent Medical through ED.
Medication reconciliation policy implemented in a critical access hospital.
Guide to Reconciling Medications.
Current medication reconciliation policy developed by an interdisciplinary team representing inpatient, outpatient & ambulatory settings.
Current medication reconciliation policy addressing medication reconciliation upon admission, transfer, and discharge and guidelines for initial patient interviews.
Medication reconciliation policy addressing reconciliation upon admission, transfer within the facility, and discharge.
Medication reconciliation policy addressing reconciliation upon admission, transfer within the facility, and discharge or transfer to another facility.
An interdisciplinary procedure for conducting medication reconciliation in a large teaching facility.
An interdisciplinary procedure for conducting medication reconciliation within 24 hours of admission and at the time of discharge in order to generate an accurate medication list and thereby decrease adverse drug events.
Preadmission Medication List Verification and Order Form Guidelines.
Medication reconciliation reviews may be conducted during the admission process, often by nurses on the admission unit, to identify unreconciled medications and potential errors or adverse events. This flowsheet helps nursing personnel perform a medication reconciliation process when patients are admitted to an intermediate care unit, either directly or as transfers from other inpatient care units.
Admission Medication Reconciliation Process for Elective Orthopedic and Emergent Medical through ED.
Forms
Admit
- Grinnell Regional Medical Center, Grinnell, IA
Medication reconciliation inpatient admission form.
- Guthrie County Hospital, Guthrie Center, IA
A medication history form used on admission.
- Mercy Medical Center, Des Moines, IA
A three page medication reconciliation/physician order form used on admission.
- University of Iowa Hospitals and Clinics, Iowa City, IA
This one page form helps pharmacy personnel perform medication reconciliation on admission.
- Luther Midelfort, Mayo Health System, Eau Claire, WI
This form aids nursing and pharmacy personnel in performing medication reconciliation when patients are admitted to an intermediate care unit, either directly or as transfers from other inpatient care units.
- Mercy Health System, Janesville, WI
This one page form helps nursing personnel perform medication reconciliation on admission.
- South Carolina Hospital Association
This is a one-page form that reconciles home [pre-admission] meds with admission meds; this version of the reconciliation form allows the MD to use the form to write admission medication orders.
- Winter Haven Hospital, Winter Haven, FL
This form was developed to obtain a list of "medications as at home" prior to admission, and it has been used extensively in all outpatient areas and on a medical/surgical unit; developed by Winter Haven Hospital (Winter Haven, Florida, USA).
Admit/Discharge
- Buena Vista Regional Medical Center, Storm Lake, IA
This one-page form was developed to aid in reconciling medications upon admission and on discharge.
- AnMed Health, SC
This is a one-page form that reconciles home [pre-admission] meds with admission meds, and with discharge meds. The difference in this form and the standard Medication Reconciliation Form is that this one allows the MD to use the form to write discharge medication orders.
- United Hospital System, Kenosha WI
A one-page form for admission and discharge reconciliation with a physician signature to verify review of discharge reconciliation.
- University of Massachusetts Memorial Medical Center, Worcester, MA
This medication reconciliation order form can be used as a tool for reconciling medications at admission and discharge.
Discharge
- Columbia St. Mary’s, WI
A five-page electronic record discharge reconciliation/order form.
- Guthrie County Hospital, Guthrie Center, IA
A reconciliation worksheet to be used upon discharge.
Transfer/Post-op
- Columbia St. Mary’s, WI
A five-page electronic record discharge reconciliation/order form.
Ambulatory Forms
- St. Mary’s Medical Center, Green Bay, WI
A one-page admission/post-op/discharge reconciliation/order form.
Medication reconciliation inpatient admission form.
A medication history form used on admission.
A three page medication reconciliation/physician order form used on admission.
This one page form helps pharmacy personnel perform medication reconciliation on admission.
This form aids nursing and pharmacy personnel in performing medication reconciliation when patients are admitted to an intermediate care unit, either directly or as transfers from other inpatient care units.
This one page form helps nursing personnel perform medication reconciliation on admission.
This is a one-page form that reconciles home [pre-admission] meds with admission meds; this version of the reconciliation form allows the MD to use the form to write admission medication orders.
This form was developed to obtain a list of "medications as at home" prior to admission, and it has been used extensively in all outpatient areas and on a medical/surgical unit; developed by Winter Haven Hospital (Winter Haven, Florida, USA).
This one-page form was developed to aid in reconciling medications upon admission and on discharge.
This is a one-page form that reconciles home [pre-admission] meds with admission meds, and with discharge meds. The difference in this form and the standard Medication Reconciliation Form is that this one allows the MD to use the form to write discharge medication orders.
A one-page form for admission and discharge reconciliation with a physician signature to verify review of discharge reconciliation.
This medication reconciliation order form can be used as a tool for reconciling medications at admission and discharge.
A five-page electronic record discharge reconciliation/order form.
A reconciliation worksheet to be used upon discharge.
A five-page electronic record discharge reconciliation/order form.
A one-page admission/post-op/discharge reconciliation/order form.
Educational Materials
Physician Education
- Institute for Safe Medication Practices
Building a Case for Medication Reconciliation.
- The Joint Commission
- Sentinel Event Alert #35
Requirements and recommendations for using medication reconciliation to prevent errors.
- FAQ’s for The Joint Commission’s 2007 National Patient Safety Goals
Questions and answers from the JCAHO website related to Goal 8, Medication Reconciliation.
- JCAHO Medication Management Update Presentation
The following information was presented in an audio conference conducted by JCAHO in 2006.
Staff Education
- Buena Vista Regional Medical Center, Storm Lake, IA
Staff education through the use of 2004-2005 JCAHO National Patient Safety Goals.
- Iowa Health System, Des Moines, IA
An educational tool used to reinforce initial staff education on electronic medication reconciliation.
- University of Iowa Hospitals and Clinics, Iowa City, IA
Medication Safety Screensaver.
- University of Iowa Hospitals and Clinics, Iowa City, IA
Guideline to Medication Reconciliation: Conducting Patient Interviews.
- Massachusetts Coalition for Prevention of Medical Errors
Example staff education materials that include staff instructions for reconciling medications at admission.
CME opportunities
- Agency for Healthcare Research and Quality
Medication Reconciliation - Case Objectives
- Appreciate the prevalence and impact of medication discrepancies at times of transition in the health care system.
- List barriers to successful medication reconciliation.
- Understand best practices for reconciling medications.
Patient Education
- Agency for Healthcare Research and Quality
AHRQ’s 60 second TV spot about “getting more involved in your healthcare”
- Agency for Healthcare Research and Quality
Get the Facts About Your Medication.
- Grinnell Regional Medical Center, Grinnell, IA
Questions every patient should ask before taking medications.
- Massachusetts Coalition for the Prevention of Medical Errors
Consumer Guide to Safe Medication Use
Building a Case for Medication Reconciliation.
- Sentinel Event Alert #35
Requirements and recommendations for using medication reconciliation to prevent errors. - FAQ’s for The Joint Commission’s 2007 National Patient Safety Goals
Questions and answers from the JCAHO website related to Goal 8, Medication Reconciliation. - JCAHO Medication Management Update Presentation
The following information was presented in an audio conference conducted by JCAHO in 2006.
Staff education through the use of 2004-2005 JCAHO National Patient Safety Goals.
An educational tool used to reinforce initial staff education on electronic medication reconciliation.
Medication Safety Screensaver.
Guideline to Medication Reconciliation: Conducting Patient Interviews.
Example staff education materials that include staff instructions for reconciling medications at admission.
Medication Reconciliation - Case Objectives
- Appreciate the prevalence and impact of medication discrepancies at times of transition in the health care system.
- List barriers to successful medication reconciliation.
- Understand best practices for reconciling medications.
AHRQ’s 60 second TV spot about “getting more involved in your healthcare”
Get the Facts About Your Medication.
Questions every patient should ask before taking medications.
Consumer Guide to Safe Medication Use
Other - Community Resources
- Medication Brochure and Wallet Card
A state-wide campaign to provide MedCards to all Iowans and improve health literacy by promoting communication between patients and healthcare providers regarding appropriate medication use.
A state-wide campaign to provide MedCards to all Iowans and improve health literacy by promoting communication between patients and healthcare providers regarding appropriate medication use.
Success Stories
Buena Vista Regional Medical Center, Storm Lake, IA
Buena Vista Regional Medical Center, Storm Lake, IA. Ongoing data collection since March, 2006 shows continued compliance at 99-100% for completion of the Med Reconciliation process on the inpatient Medical-Surgical Unit. We are currently developing the process for compliance monitoring for the other inpatient units and ambulatory settings.
Additionally -
Medication reconciliation is carried out into the community setting via the use of follow-up discharge phone calls. Patient Care Coordinators make a telephone call to each patient discharged from the medical-surgical unit, within 24-48 hours of discharge. Included in this phone call is an additional review of the medications ordered at the time of discharge, and the patient is asked whether all prescriptions were filled and whether they have any additional questions or concerns about the use of their medications. This provides an opportunity for futher clarification, teaching and verification of medications ordered at the time of discharge.
Prevent Adverse Drug Events (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 inpatients 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.
Mercy Medical Center, Des Moines, IA
Improving Medication Reconciliation Across Settings: Using Six Sigma Methodology
Read Story (PDF Format)
Regional Medical Center, Manchester, IA
Our facility (RMC, Manchester) committed to IHI 100,000Lives Campaign in the spring of 2005. Phase I included development of a tool to obtain as accurrate medication history as possible from the patient presenting in ER, OR, Ambulatory Surgery, Medical-Surgical and Intensive Care units. This tool was developed by the Patient Safety Committee, co-chaired by our Pharmacy and Quality Managers. This committee also has a physician champion that is very actively engaged in all of our patient safety initiatives. This tool is in triplicate, which also functions as a physician order sheet thus avoiding potential for transcription errors. This process has slowly but steadily evolved to the point that all physicians, nurses, and pharmacists are involved in the intended use of this document. From that, we developed a discharge record specific to medication the patient was to continue on at home following discharge. It is in larger print, and utilizes symbols like a stop sign that indicates to the patient what medications have been discontinued. A copy is sent to the physician’s office after the patient is discharged.
In the spring of 2006, our Patient Safety Committee, under the direction of our physician champion, and at the request of members of our Medical Staff, accepted the challenge to begin Phase II of 100,000Lives Campaign. Phase II involved marketing and engaging patients in our community to know what medications they were taking, why they were taking them, and how to take them. This involved the development of a medication card that could be given to patients at various access places from all medical providers, and businesses in our community. The committee reviewed the medication reconciliation tool kit that was available online from the Iowa Healthcare Collaborative. Having this toolkit available to us proved to be invaluable from the standpoint of not having to spend hours re-inventing the wheel. The committee reviewed the medication card and made the changes we felt most appropriate for our community. From there it was taken to our Medical Staff for further suggestions. Their direction and support was very encouraging, and they continued to push for a product that they could give and educate the patient/public on in relationship to them taking ownership of their medications.
The physicians asked for more space for medications to be written so the elderly patient could read and write on it, space for a brief medical/surgical history, and allergies that would fit into a male/female billfold. We decided to make ours slightly larger, with a different layout from the toolkit, and found that when folded properly we could fit it into a baseball card sleeve protector. These were less expensive than the ones suggested in the toolkit. The trade off was that the base ball sleeve was flimsier; but still effective. We placed our hospital logo on the sleeve, and saved a lot of room on the card itself. The final product with a full marketing plan was taken to our full Medical Staff in August. The Medical Staff unanimously voted to support this initiative, and voted to put $1000 from their fund to help with advertising and printing of the cards. The hospital and hospital auxiliary have equally donated funds to help sustain this project.
Manchester has a population of 6,000. Our service area is approximately 22,000 people. RMC hosted an Open House to members of this service area in September. One identified stop on the tour was our Medical Staff meeting room which contained a brief presentation on Medication Matters project and distribution of the cards. Over 600 cards were distributed that day. Since then, we have hosted a breakfast brunch for all medical providers (dentists, pharmacists, optometrists, chiropractors, physicians, mental health providers) in our area to promote this initiative and provide them with a holder and packet(obtained from the IHC website containing the medication card). All of the local pharmacies have also assisted with providing funds to educate and market this initiative on our local radio station and in the local newspapers. I have attached copies of these advertisements. To date over 5000 of the cards have been distributed by these providers. The hospital has committed to continue to be the contact and supplier of the medication cards for the participating providers. We have even developed an audiovox message regarding this initiative ( see attached),the message plays on our hospital phone system, so when a caller is on hold, we educate on the use of the card and where to obtain one. We have also had various written articles from our pharmacist in the local papers.
Hopefully, now we will see patients use the card......so far we have seen some usage as people come in for surgery and scheduled procedures. There is still a lot of work to be done to educate the public. We monitor how many cards we distribute to each provider, so we can receive feedback on whether or not they are offering the card, and have it available to patients. Thanks again to the efforts of all the people involved in placing the toolkit on the IHC website!
Mentors
Iowa Mentor Hospitals in Preventing Adverse Drug Events - 100,000 Lives Campaign
- Buena Vista Regional Medical Center, Storm Lake, IA
Michele Kelly, Director of Quality
Email: kelly.michele@bvrmc.org
- Kossuth Regional Health Center, Algona, IA
Dar Elbert, RN, MS, Nurse Executive
Email: elbertd@mercyhealth.com
- Buena Vista Regional Medical Center, Storm Lake
Pat Thies
Email: ThiesPW@crstlukes.com
Contributing Iowa Hospitals:
We would like to thank those organizations who have shared their materials. We ask that organizations using example materials to properly attribute them. Please contact IHC if your organization would like to share materials related to Medication Reconciliation.
- Allen Memorial Hospital - Waterloo
- Buena Vista Regional Medical Center - Storm Lake
- Guthrie County Hospital - Guthrie Center
- Iowa Health System - Des Moines
- Mercy Medical Center - Des Moines
- Mercy Medical Center - North Iowa - Mason City
- St. Luke's Hospital - Cedar Rapids
- The University of Iowa Hospitals and Clinics - Iowa City
Michele Kelly, Director of Quality
Email: kelly.michele@bvrmc.org
Dar Elbert, RN, MS, Nurse Executive
Email: elbertd@mercyhealth.com
Pat Thies
Email: ThiesPW@crstlukes.com
Resources
Articles
- Massachusetts Coalition for the Reduction of Medical Errors
Reconciling medications reference articles.
- Health Leaders Media
There’s No ‘I’ in Med Rec by Molly Rowe, June 20, 2008.
- Pharmacy Practice News
The following articles have been reprinted with permission from Pharmacy Practice News. For more articles by DeeAnn Wedemeyer Oleson, visit www.pharmacypracticenews.com and click on the “Columnists” button on the left side of the home page.
- Nine Habits of Building a Successful Discharge Medication Education Service
- Admission Medication History Service Part 1 Reconcilable Differences
- Admission Medication History Service Part 2 Reconcilable Differences
- Admission Medication History Service Part 3 Reconcilable Differences
- A Systematic Approach to Tracking Drugs at Discharge
- Rural Hospitals as Pharmacy Student Training Sites
Reconciling medications reference articles.
There’s No ‘I’ in Med Rec by Molly Rowe, June 20, 2008.
The following articles have been reprinted with permission from Pharmacy Practice News. For more articles by DeeAnn Wedemeyer Oleson, visit www.pharmacypracticenews.com and click on the “Columnists” button on the left side of the home page.
- Nine Habits of Building a Successful Discharge Medication Education Service
- Admission Medication History Service Part 1 Reconcilable Differences
- Admission Medication History Service Part 2 Reconcilable Differences
- Admission Medication History Service Part 3 Reconcilable Differences
- A Systematic Approach to Tracking Drugs at Discharge
- Rural Hospitals as Pharmacy Student Training Sites
Additional Toolkits
- American Society of Health-System Pharmacists
Medication Reconciliation Toolkit
- Legacy Health System
Medication Reconciliation: Bridging Communications Across the Continuum of Care
Medication Reconciliation Toolkit
Medication Reconciliation: Bridging Communications Across the Continuum of Care