Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team

Abstract

Medication reconciliation is an important component to the care of hospitalised patients and their safe transition to the ambulatory setting. In our Family Medicine Hospitalist Service, patient care is frequently transferred between the various physicians, residents, nurses and eventually to a separate group of providers who provide ambulatory management. Due to frequent transitions of care, there was no clear ownership of the medication reconciliation process. To improve the medication reconciliation process, a Transition of Care Team composed of registered nurses was created to oversee the entire reconciliation process. The team engaged the patient and their family, when needed, contacted patients' pharmacies and their providers, reconciled the patients' hospital medication list with the ambulatory list at hospital admission and within 24 hours of discharge, and attended the hospital follow-up visit to verify medications and provide continuity of care. Implementation of the team allowed for additional investigative resources, redundancy in preventing errors and early recovery should an error occur. The percent of medications with error after implementation of the Transition of Care Team was reduced from 131/386 (33.9%) to 147/787 (18.7%) at hospital admission, 81/354 (22.9%) to 42/834 (5.0%) at discharge and 43/337 (12.8%) to 6/809 (0.7%) at follow-up visit (two proportion tests, p<0.001). In addition, the percent of charts without any errors improved at hospital discharge from 8/31 (25.8%) to 46/70 (65.7%) and at hospital follow-up visit from 16/31 (51.6%) to 64/70 (91.4%) (two-proportion test, p<0.001). Previously viewed as three separate reconciliations occurring at admission, discharge and hospital follow-up, the approach to medication reconciliation was reframed as a continuous process occurring throughout the hospitalisation and hospital follow-up resulting in improved reconciliation accuracy and safer transitions to the ambulatory setting.

Keywords: ambulatory care; healthcare quality improvement; medication reconciliation; medication safety; six sigma.

Figure 1

Medication reconciliation process at hospital admission, discharge and follow-up visit. At hospital admission, nursing staff complete a two-step verification of medications, update the electronic record and notify the resident to sign off on the list. At discharge, medications are reconciled in the hospital and ambulatory records are forwarded to the patient’s provider. At hospital follow-up visit, both nursing staff and residents verify the medication list. Frequently, the admitting, verifying, discharging and hospital follow-up residents are different individuals. The Transition of Care Team begins ambulatory medication reconciliation at admission, reviews the list again within 24 hours of discharge and attends the follow-up visit to provide continuity of care. Use of the Transition of Care Team removed the silo structure of the initial medication reconciliation process. FMHS, Family Medicine Hospitalist Service.

Figure 2

Percentage of medications with errors was reduced at hospital admission, discharge and follow-up visit after implementation of the Transition of Care Team. Percent medications with errors was measured by a convenience sample of 31 patients before the intervention and 70 patients after the intervention. Medication errors were counted only once even if the medication had more than one type of error. Two-proportion test, *P<0.001.

Figure 3

Percent of charts without any errors was increased at hospital discharge and follow-up visit after implementation of the Transition of Care Team. Percent charts without errors was measured by a convenience sample of 31 patients before the intervention and 70 patients after the intervention. Two-proportion test, *P<0.001.