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Medication Reconciliation Review
The Medication Reconciliation Review tool provides step-by-step instructions
for conducting a review of closed patient records to identify errors related to
unreconciled medications. Organizations that are considering creating a
medication reconciliation process can use this tool to establish a baseline of
errors from unreconciled medications and to build a case for the importance of
having a reconciliation process in place
This tool contains:
Overview
Instructions
Data Collection Form: Errors from Unreconciled Medications
Roger Resar, MD
Luther Midelfort — Mayo Health System
Eau Claire, Wisconsin, USA
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Institute for Healthcare Improvement
Boston, Massachusetts, USA
Copyright © 2004 Institute for Healthcare Improvement
Medication Reconciliation Review
Overview
Reconciliation is a process of identifying the most accurate list of all medications a patient is
taking — including name, dosage, frequency, and route — and using this list to provide correct
medications for patients anywhere within the health care system. Reconciliation involves
comparing the patient’s current list of medications against the physician’s admission, transfer,
and/or discharge orders.
Experience from hundreds of organizations has shown that poor communication of medical
information at transition points is responsible for as many as 50 percent of all medication errors
and up to 20 percent of adverse drug events (ADEs) in the hospital. Each time a patient moves
from one setting to another, clinicians should review previous medication orders alongside new
orders and plans for care and reconcile any differences. If this process does not occur in a
standardized manner designed to ensure complete reconciliation, medication errors may lead
to adverse events and harm.
Tallying the number of errors related to unreconciled medications establishes a baseline that
tells hospitals how much harm is caused to patients because of poor or nonexistent processes
for reconciling medications. Establishing a baseline can help organizations make the case for
improving or establishing such processes; tracking this measure over time can help
organizations to see if changes they make are leading to improvement.
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Copyright © 2004 Institute for Healthcare Improvement
Medication Reconciliation Review
Instructions
1. Identify a multidisciplinary team consisting of, at a minimum, a nurse, a pharmacist, and a
physician.
2. Obtain a set of approximately 20 to 30 closed patient records (each with a minimum stay of
3 days), using as random a selection process as possible.
3. Have each team member review one-third of the patient records, counting errors due to
unreconciled medications.
Tips for Finding Errors Due to Unreconciled Medications
a. Look for discrepancies in medication orders between outpatient and inpatient settings,
pre- and post-intra-hospital transfers, and discharge documents, using the following
steps:
b. Compare all medications ordered upon admission with any available information about
medications the patient was taking prior to admission. Each medication that is not
ordered or commented on represents a discrepancy and should be counted as an error.
Exclude the obvious. (Example: “Patient admitted for bleed due to warfarin; warfarin
not continued” would be obvious. Since the medication was intentionally discontinued,
this is not an error.)
c.
Look for any other evidence of medication errors resulting from a medication that was
not continued inadvertently on the medication administration record (MAR), incident
reports, or nursing or physician notes.
d. Look for any adverse drug events that might be in the charts or discharge summaries.
Then review the details to see if the ADE was the result of the inadvertent
discontinuation of a medication or an order that was missed at a point of transition (at
admission, transfer to another patient care unit, post-procedure, or discharge). If you
find this, it counts as an error, as well as being an ADE. In U.S. hospitals only, also
review the list of diagnosis codes that have been assigned to the case by medical staff
and see if any of the codes start with the letter “e”; these are complication codes and
the complication may be the result of an ADE.
e. Look for any discrepancies between the discharge medications and the medications that
were on the MAR. Any medication discrepancies not accounted for are considered
errors.
f.
On the transfer from one patient care unit to another, look for medications that are still
on the MAR that cannot be used in the receiving unit. Those are errors.
4. Tally errors from unreconciled medications.
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Copyright © 2004 Institute for Healthcare Improvement
Medication Reconciliation Review
After the records have been reviewed, add up all the errors from unreconciled medications and
note the number of patient records reviewed. Report data as a monthly number of errors per
100 admissions. On average, two to three errors are noted per 100 admissions. Then look at
these errors and find out how many occur due to the handoffs of care at admission, transfer, or
discharge. On average, about 50 percent usually occur in this area.
Note: If you find very few errors, suspect the quality of the review; don’t assume the
reconciliation process is already very good.
Medication reconciliation is a process that has a well-established set of standardized methods
to ensure that the right medication is given. The baseline measurements above should serve
only to support the case for improvement. As improvements to the medication review process
are tested and implemented, most organizations conduct retrospective reviews of patient
records from only those patients who have been through a medication reconciliation process.
This allows the organization to measure the success of the changes. If subsequent reviews are
conducted in this manner, the results should not be compared to the baseline data.
Generally, changes to the admission medication reconciliation process have the greatest effect
on prescribing and ordering errors, and changes to the discharge medication reconciliation
process have the greatest effect on adverse drug events. Once an organization has
reconciliation processes in place throughout the entire organization, it may conduct another
review using the same method to obtain another baseline and the data may then be compared.
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Copyright © 2004 Institute for Healthcare Improvement
Medication Reconciliation Review
Medication Reconciliation Data Collection Form:
Errors from Unreconciled Medications
Patient
Record
Review
Date
Errors at
Admission
Errors during
Transfer
Errors at
Discharge
Total Errors
Number of
Records
Reviewed
Total Errors
from Records
Reviewed
Total
Records
Reviewed
1
2
3
4
5
Etc.
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Copyright © 2004 Institute for Healthcare Improvement