Assuring that every patient gets the right medications following each transition of care requires addressing the core issues of teamwork and communication and information transfer. Success requires a cooperative effort, with caregivers sharing responsibilities across disciplines and units. You will be required to change how people do work, and will meet with resistance as a result. The case studies of successful hospital programs to implement the reconciling procedures highlight four fundamental ingredients for success:
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.
Leadership engagement is a fundamental component of a successful reconciling medications implementation effort. Hospital teams participating in the Reconciling Medications Collaborative have had identified the following tasks for leadership to support the implementation teams:
Form a Team
Identify a multidisciplinary team to direct your Medication Reconciliation
Collect Baseline Data
Begin a risk assessment of your current processes, collecting baseline data and developing high-level flow charts of existing workflow. It can also be helpful to review any root cause analysis of recent medication errors occurring at the interfaces of care and develop a mini-FMEA identifying what can go wrong at admission relative to collecting the patient’s home medication list and ensuring that that list is accurately reflected in the admit orders.
Instructions for collecting baseline data and an accompanying Excel spreadsheet can be found in the Measures section: Forms for Baseline Data Collection
Develop Mission and Aim Statements
Example mission and aim statements are provided below. The key is to frame a mission statement that reflects the project’s goal in reducing adverse medication events for the patient, coupled with an aim statement that includes both a quantified goal and a timeframe for achieving that goal.
Broad Mission Statement
Every patient will receive all medications they have been taking at home unless they are held/discontinued by their caregiver(s) and all new medications as ordered -- correct drug, dose, route, and schedule.
The goal of reconciling is to design a process that will ensure the most accurate patient home medication list available, thus reducing the number of medication events upon admission, transfer and discharge.
Choose Where to Start
A lot of different ingredients have gone in to hospitals’ selection of where to start testing the reconciling procedures, and there has been a wide variation in their choices. For some, the emergence of a physician champion on a particular unit has dictated the choice. For others, a medication error has triggered activity in a specific location. Some hospitals combined their baseline data collection efforts with a mini-FMEA process to assess the areas with the greatest potential for problems.
The most common place for organizations participating in the Collaborative to start has been in pre-admission testing (PAT), where they can take advantage of the pre-admission contact with the patient to develop an accurate home medication list. For nursing units, there have been many provocative discussions about the advantages of starting on medical versus surgical units. Chronically ill patients on the medical floors are often at great risk because of multiple conditions, multiple medications. Surgical patients with underlying medical conditions are often on medications that will need to be re-started post-op, another significant safety risk.
While most hospitals are focusing on starting with the admission phase, there is lots of great evidence on the effectiveness of reconciling on transfer out of the ICU in preventing medication errors (see 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.) Peter Pronovost’s work at Johns Hopkins on reconciling at transfer from the ICU is well documented on the www.qualityhealthcare.com WEB site, including his measurement template. Among our collaborative participants, one of our great success stories was a hospital with an extremely large mental health population that began their reconciling implementation in the ICU, with a very powerful MD champion who consistently used the evidence of the impact that failure to re-start psychotropic meds was having on their patient population!
Starting in the ED is not usually recommended, since not all patients will be admitted and the urgency of the environment results in clinician focus on other issues. However, there are opportunities to take advantage of wait times for patients who are being admitted to start the reconciling process by developing the home medication list. (Additional comments can be found at this link: Special Issues for Reconciling in the ED).
Once you have identified your pilot unit, you’ll want to begin small tests of change. We strongly suggest breaking the process down into small steps, so you will have narrow, focused tests to work out the kinks in the process. You can begin with just the first step, taking the patient’s medication history, and then introduce the reconciling step, having someone compare the admit orders to the pre-admit medication list and reconcile differences, and then later on build toward having the ordering prescriber use the history when writing orders. Some ideas to help you get started:
A set of implementation planning tools are provided in the “Toolkit” section of this WEB site:
The most important thing is to stay focused; start small and test each step of the process:
This collaborative is supported in part by grant number 5 U18 HS011928 from the Agency for Healthcare Research and Quality (AHRQ)