TMIT has developed QuickStart Packages™ to aid leaders in the adoption of the NQF 34 Safe Practices for Better Healthcare at your organization.
A QuickStart Package™ is a set of multimedia resources that will aid in the implementation of the NQF Safe Practices for Better Healthcare. We have developed a QuickStart Package™ for each of the 34 safe practices. These packages contain:
A slide set outlining the history of the practices, the harmonization effort culminating in their creation, data to support the problem addressed, the practice, and evidence-based implementation examples that can be used in your organization.
A set of videos that can be downloaded and used in your presentations. They will include explanations of the problem, practice, and implementation aspects of the practice, humorous clips, and real success stories from the front line to help tell the story of the practice and drive adoption.
A collection of peer-reviewed articles and resources that support the practice
Get started with implementation at your organization by selecting a Safe Practice through the provided links and downloading the full QuickStart Package™.
QuickStart for SP #17: Medication Reconciliation
Click here to download Safe Practice #17 in PDF format. To save to your computer, right-click and select "Save Target As . . ." The safe practice
full text in html format is located under the video preview box below.
Click on the video link below to access three previews of videos that can be accessed at the video tab to the right, downloaded and used in your presentations. They include explanations of the problem leading to the Safe Practice
and implementation of the Safe Practice in addition to humorous clips and real success stories from the front-line to help tell the story of the practice and drive adoption.
Click here to order a complete copy of the NQF Safe Practices for Better Healthcare — 2010 Update which
is important for effective use of the safe practice implementation toolboxes.
Other resources such as slides and articles to help you implement this Safe Practice are located in the tabs to the right.
The healthcare organization must develop, reconcile, and communicate an accurate medication list throughout the continuum of care.
Medication reconciliation is a process of
identifying the most accurate list of all medications
a patient is currently taking, and using
this list to provide correct medications for the
patient in all care settings within the healthcare
system. [IHI, 2008] The goal of medication
reconciliation is to reduce adverse drug events
(ADEs) during transitions of care. [TJC, 2006]
A meta-analysis of 22 studies focusing on
medication history discrepancies found that
10 to 67 percent of patients had at least one
prescription medication history error at hospital
admission. When nonprescription drugs were
included, the frequency was 27 to 83 percent;
and when information on drug allergies
and prior adverse events was included, the
frequency was 34 to 95 percent. [Tam, 2005;
Gleason 2004] Many of these medication
history errors occur upon admission to or
discharge from a clinical unit of the hospital.
A study of 4,108 patients found that 46 percent
of errors occur at these junctions. [Bates,
1997] A similar study of 250 medication
history errors found that approximately
60 percent of errors occurred at these times.
The frequency of medication reconciliation
errors is estimated to be 20 percent of adverse
drug events (ADEs) within hospitals. [Rozich,
2001] A large study of 2,022 medication
errors involving reconciliation, conducted by
the United States Pharmacopeia, found that
22 percent occurred at admission, 66 percent
occurred during transitions in care, and
12 percent occurred at the time of discharge.
[Santell, 2006] A study following patients two
weeks after hospital discharge found that ADEs
occur in approximately 12 percent of patients.
The severity of these events has been
measured in several studies. Cornish et al.
found that 61.4 percent of errors had no
potential to cause serious harm, and the
remaining 38.6 percent had potential to
cause moderate to severe discomfort or
clinical deterioration. [Cornish, 2005; Levinson,
2008a; Levinson, 2008b] A study in 1990
reported that about 6 percent of patients may
experience a drug discrepancy of a serious
nature at hospital admission. [Van Hessen,
1990; Etchells, 2006] Gleason et al. reported
that 55 percent of medication discrepancies
would have been unlikely to cause harm, 23
percent would have necessitated monitoring or
precluded harm, and 22 percent would have
resulted in serious harm had the pharmacist
not intervened. [Gleason, 2004] Patients with
a higher severity of illness, or who were taking
numerous medications, were more likely to
have a higher risk for ADEs. [Gleason, 2004]
Another study of 1,459 emergency department
admissions showed that 41 percent of medication
reconciliation errors were clinically important.
[Akwagyriam, 1996] Another found that
3 percent of patients had missing medications
in their history that were “life-saving,” and
that 24 percent of patients would have gained
significant benefit if their missing medications
had been included. [Cohen, 1998] In a study
of 180 patients on a general medicine service,
939 unintentional medication discrepancies
were found, of which 257 had potential for
patient harm (1.4 potential adverse drug
events [PADEs] per patient); 54 percent had at
least one PADE. Seventy-two percent of these
PADEs related to the reconciliation process were
due to errors in taking the medication history
rather than in reconciling the medications with
admission or discharge orders. The majority
of PADEs occurred at discharge (75 percent)
as opposed to at admission, and 60 percent
were due to omissions of medications.
Preventable adverse events from medication
errors affect approximately 2 out of every 100
patients admitted to the hospital, and adverse
events outside the hospital are estimated to
account for 4.7 percent of hospital admissions.
[Leape, 1994; Kanjanarat, 2003; Lazarou,
1998] Effective preventability strategies for the
reduction of medication errors and subsequent
ADEs have been found through successful
medication reconciliation processes. [Nickerson,
2005; Bartick, 2006; Boockvar, 2006; Vira,
2006] A multicenter study of 50 hospitals
found that reduction of errors and ADEs is
most strongly correlated with active physician,
pharmacist and nurse engagement; having an
effective improvement team; using small tests of
change; having an actively engaged senior
administrator; and sending teams to multiple
collaborative sessions. [Rogers, 2006] A study
of one critical care unit found that the use of a
discharge survey resulted in a reduction from
94 percent of patients having orders changed
to 0 percent. [Pronovost, 2003] Another study
performed in an outpatient setting found that:
1) mailing letters prior to appointments to
remind patients to bring medication bottles and
updated medication lists; 2) verifying updated
lists; and 3) correcting medication lists in the
electronic medical record decreased medication
discrepancies by 50 percent from 5.24
discrepancies per patient to 2.46. [Varkey,
2007] Involving a pharmacist in medication
history taking has also been reported to
reduce medication errors by 51 percent.
[Bond, 2002] Computerized prescriber order
entry (CPOE) systems can effectively reconcile
medications, but these systems are only as
good as the data entered into them. CPOE
systems alone, without effective reconciliation
strategies, are likely to be ineffective. [Anderson,
2007; Groeschen, 2007; Lawrence, 2007;
TJC, 2007; Yu, 2007; Bails, 2008] A recent
two-site randomized controlled trial of an
information technology-assisted medication
reconciliation intervention found a 38 percent
relative risk reduction in potential ADEs. Patients
at highest risk for PADEs were more likely
to benefit from the intervention. Errors still
remained even in the intervention group,
most often due to incomplete and inaccurate
electronic sources of ambulatory medication
information, lack of patient and caregiver
knowledge of preadmission medication
regimens, lack of clinician adherence with the
reconciliation process, and software usability
issues. [Turchin, 2008; Schnipper, 2009]
The costs associated with all ADEs are
estimated to be about $3.8 million per year
per hospital, of which approximately $1 million
is preventable. [Classen, 1997] Another study
found that ADEs increased patients’ length
of stay by 2.2 days and increased costs by
$3,244 and that preventable events caused an
increased length of stay of 4.6 days and an
increased cost of $5,857 per patient. For the
700-bed teaching hospital studied, annual
costs for ADEs and preventable ADEs were
$5.6 million and $2.8 million, respectively.
Although reducing medication errors related
to medication reconciliation has been a Joint
Commission safety goal since 2005, hospital
implementation is still in the early stages, and
these changes are yet to be fully tested. In
2007, The Joint Commission hosted a one-day
Summit on Medication Reconciliation, with the
goal of discussing the challenges associated
with reconciling medications in various healthcare
settings, identifying best practices, and
bringing forth potential refinements to medication
reconciliation practices. The consensus
was that the process of medication reconciliation,
obtaining an accurate medication list
from the patient, and ensuring its accuracy
throughout the care continuum improves
patient safety; however, more guidance on
implementation is required. [TJC, 2009]
Preliminary data suggest that an accurate
medication history, coupled with an electronic
medication reconciliation process, may
reduce adverse drug events due to medication
discrepancies. [Schnipper, 2009] Processes
using both electronically available medication
records as well as data from patient/family
interviews have been proposed as potential
solutions. [Agrawal, 2009; Cutler, 2009]
NQF recognizes that medication reconciliation
is critically important for patient safety
but that it also represents a set of processes
that are difficult for organizations to implement.
NQF continues to monitor the scientific evidence
and the availability of best practices for
medication reconciliation. As further evidence
clarifies the issues of medication reconciliation,
NQF will adjust this safe practice.
Safe Practice Statement The healthcare organization must develop,
reconcile, and communicate an accurate
patient medication list throughout the continuum
of care. [LMMHS, 2004; SHM, 2008; ASHP,
2009; IHI, 2009; JCR, 2010]
Additional Specifications [JCR, 2010]
Educate clinicians upon hire on the importance of medication reconciliation; frequency of ongoing education is based on the risk of noncompliance and adverse drug
events as determined by the organization. [AHRQ, N.D.b]
Providers receiving the patient in a transition of care should check the medication reconciliation list to make sure it is accurate and in concert with any new medications that are ordered/prescribed.
The list should include the full range of medications as defined by accrediting organizations such as The Joint Commission. At a minimum, the list should include the following:
complementary and alternative medications;
respiratory therapy-related medications;
intravenous solutions (plain or with additives);
investigational agents; and
any product designated by the Food and Drug Administration (FDA) as a drug.
At the time the patient enters the organization or is admitted, a complete list of medications the patient is taking at home (including dose, route, and frequency) is created and documented. The patient, and family, as needed, are involved in creating this list.
The medications ordered for the patient while under the care of the organization are compared to those on the list created
at the time of entry to the organization or admission. According to The Joint Commission's FAQ, organizations should keep two lists during the hospitalization. The “home medications” list should be maintained unchanged and available for subsequent use in the reconciliation process. The list of the patient’s current medications while in the hospital is a dynamic document that will require updating whenever changes are made to the patient's medication regimen. Both lists should be considered whenever reconciliation is carried out. The reason for referring to the “home” medication list is that some “home” medications may be held when a patient is admitted or goes to surgery. They may need to be resumed upon transfer to a different level of care, return from the operating room, or at discharge. [JCR, 2010]
Any discrepancies (i.e., omissions, duplications, adjustments, deletions, additions) are reconciled and documented while the patient is under the care of the organization.
When the patient’s care is transferred within the organization (e.g., from the ICU to a floor), the current provider(s) inform(s) the receiving provider(s) about the up-to-date reconciled medication list and documents the communication.
The patient's most current reconciled medication list is communicated to the next provider of service, either within or outside the organization. The communication between providers is documented.
At the time of transfer, the transferring organization informs the next provider of service of how to obtain clarification on the list of reconciled medications.
When the patient leaves the organization’s care, the current list of reconciled medications is provided to the patient, and family, as needed, and is explained to the patient and/or family, and the interaction is documented. [Jack, 2009; AHRq, N.D.a]
In settings where medications are used minimally, or are prescribed for a short duration, modified medication reconciliation processes are performed:
The organization obtains and documents an accurate list of the patient’s current medications and known allergies in order to safely prescribe any setting-specific medications (e.g., IV contrast, local anesthesia, antibiotics) and to assess for potential allergic or adverse drug reactions.
If no changes are made to the patient's current medication list, or when only short-term medications (e.g., a preprocedure medication or a short-term course of an antibiotic) will be prescribed, the patient, and family, as needed, are provided with a list containing the short-term medication additions that the patient will continue after leaving the organization.
In these settings, there is a complete, documented medication reconciliation process when:
Any new long-term (chronic) medications are prescribed.
There is a prescription change for any of the patient’s current known long-term medications.
The patient is required to be subsequently admitted to an organization from these settings for ongoing care.
When a complete, documented, medication reconciliation is required in any of these settings, the complete list of reconciled medications is provided to the patient and the patient's family, as needed, and to the patient's known primary care provider or original referring provider, or a known next provider of service.
Applicable Clinical Care Settings
This practice is applicable to Centers for Medicare & Medicaid Services care settings, to include ambulatory, ambulatory surgical center, emergency room, dialysis facility, home care, home health services/agency, hospice, inpatient service/hospital, outpatient hospital, and skilled nursing facility.
Example Implementation Approaches
Develop and use a template medication reconciliation form to gather information about current medications and medication allergies, to standardize care, and to prevent errors.
The Medical Executive Committee should aid in the creation and reinforcement of medication reconciliation.
Identify internal champions to lead implementation of the practice within the organization.
Educate providers about reviewing the necessity of medications upon admission and discharge, to further streamline medication lists and reduce ADEs.
Any changes from the “home” medication
list should be clearly noted and explained to
the patient. [Jack, 2009; AHRQ, N.D.a]
Include patient health literacy, feasible
dosing schedules, and affordability, as
well as cultural, physical, or environmental
barriers, when creating individual patient
Review and draw upon sources of fully developed implementation solutions, such as those of the Massachusetts Coalition for Prevention of Medical Errors (http://www.macoalition.org/) and the Institute for Healthcare Improvement. [MCPME, N.D.; IHI, 2008]
Use of over-the-counter or complementary and alternative medication (CAM) should be included in provider education about medications, and providers should then educate patients about the state of scientific knowledge with respect to CAM therapies that the patient may be using or thinking about using.
Encourage patients to carry an accurate medication list with them and share with their healthcare providers, including the community pharmacist. [ISMP, 2007; ASHP, 2008]
Some organizations have referred to patient home medication bottles and contacting the patient's home pharmacy to assist in the creation of an accurate home medication list to help clinicians when making medication decisions.
Use consumer-based kiosk technology to
improve medication reconciliation and
decrease facility costs. [Lesselroth, 2009]
Safe medication ordering practices, such as use of order sets or preprinted orders, drug interaction software, and implementation of other performance improvement methods, may be led by pharmacy leaders across the organization.
Strategies of Progressive Organizations
According to recently published research, implementation strategies most strongly correlated with success include an active interdisciplinary focus (physician, pharmacist, and nurse engagement); having an effective improvement team; using small tests of change; having an actively engaged senior administrator; and having teams participate in collaborative initiatives.
High-performing organizations have required second check systems by a separate care provider to validate patient medication home lists.
Consider including budgetary resources to financially support the medication reconciliation process through additional dedicated staff or technology support systems.
Institutions with Computerized Practitioner
Order Entry should consider IT-supported
medication reconciliation systems.
Conduct pharmacist review of admission,
transfer, and discharge medication lists.
Have pharmacists collect accurate medication
histories on patients identified as high risk
for medication errors. [Kaboli, 2006;
Opportunities for Patient and Family Involvement
Encourage patient and family members to ask questions about the appropriate usage of their medications.
Engage patient and family members to carry accurate medication lists, and to share those lists with healthcare professionals during
office visits, hospitalizations, and community pharmacy encounters. The list should be
updated with each medication change, and
patients should encourage their healthcare
provider to assist them in verifying accuracy
of the list every six months.
Use the teach-back method to ensure patient/family understanding of appropriate medication use. Example: Have patients or family members, as appropriate, demonstrate the administration of medications that involve injections or inhalation devices.
Patient and family members should be instructed how to identify and manage routine side effects and to know when and whom to contact if they believe the patient is experiencing any serious adverse effects of drug therapy. Pharmacists involved
in this education during discharge can offer
accurate information about changes in the
patient’s previous medication list and the
discharge medication list and can assist
with managing barriers to medication
adherence. [Dudas, 2001; Coleman, 2006;
Consider including patients or families of patients who have experienced medication-related adverse events to serve on appropriate patient safety or performance improvement committees.
Outcome, Process, Structure and Patient-Centered Measures These performance measures are suggested for consideration to support internal healthcare organization quality improvement efforts and may not necessarily address all external reporting needs.
Outcome Measures include ADEs causing harm to patients, including death, disability (permanent or temporary), or preventable harm requiring further treatment, and operational and financial outcomes, including break-even analysis.
Process Measures include evidence of
reconciliation having occurred; number of
unreconciled medications per a specified
number (e.g., per 100) of patient admissions;
unreconciled medications per patient;
and/or total number of patients with
unreconciled medications in the area of
focus. A reasonable goal for an organization
is to reduce the percentage of unreconciled
medications in an area of focus (admission,
transfer, or discharge) by 75 percent or
more. Furthermore, if the medication history
has been taken, the medication list drawn
up, and the reconciliation process has
occurred, their accuracy, can be measured.
[NQF, 2009; Stock, 2009]
National Quality Forum (NQF)-endorsed® process measures:
#0019Documentation of medication list in the outpatient record (Ambulatory): Percentage of patients having a medication list in the medical record.
#0020Documentation of allergies and adverse reactions in the outpatient record (Ambulatory): Percentage of patients having documentation of allergies and adverse reactions in the medical record.
#0097: Medication Reconciliation
[Ambulatory Care (office/clinic)]:
Percentage of patients aged 65 years
and older discharged from any
inpatient facility (e.g., hospital, skilled
nursing facility, or rehabilitation facility)
and seen within 60 days following
discharge in the office by the physician
providing ongoing care who had a
reconciliation of the discharge medications
with the current medication list in
the medical record documented.
#0293: Medication Information
[Emergency Department]: Percentage
of patients transferred to another acute
hospital whose medical record documentation
indicated that medication
information was communicated to the
receiving hospital within 60 minutes of
#0419: Universal Documentation and
Verification of Current Medications in
the Medical Record [Hospital, Nursing
home/Skilled Nursing Facility (SNF),
Ambulatory Care (office/clinic)]:
Percentage of patients aged 18 years
and older with a list of current medications
with dosages (includes prescription,
over-the-counter, herbals, vitamin/
mineral/dietary [nutritional] supplements)
and verified with the patient or
authorized representative documented
by the provider.
#0553: Care for Older Adults –
Medication Review (COA) [Ambulatory
Care (office/clinic), Health Plan]:
Percentage of adults 65 years and
older who had a medication review.
#0554: Medication Reconciliation
Post-Discharge (MRP) [Ambulatory Care
(office/clinic), Health Plan]: Percentage
of discharges from January 1 to
December 1 of the measurement year
for patients 65 years of age and older
for whom medications were reconciled
on or within 30 days of discharge.
#0560: HBIPS-5 Patients discharged
on multiple antipsychotic medications
with appropriate justification [Hospital]:
Patients discharged from a hospital-based
inpatient psychiatric setting on
two or more antipsychotic medications
with appropriate justification.
Structure Measures include verification of the implementation of medication reconciliation and the formal reporting to governance and senior management of performance improvement toward established target aims and goals.
NQF-endorsed structure measures:
#0486: Adoption of Medication
e-Prescribing [Ambulatory Care
(office/clinic), Community Healthcare,
Other]: Documents whether provider
has adopted a qualified e-Prescribing
system and the extent of use in the
#0487: EHR (electronic health record)
with EDI (electronic data interchange)
prescribing used in encounters where a
prescribing event occurred [Can be
used in all healthcare settings]: Of all
patient encounters within the past
month that used an EHR with EDI
where a prescribing event occurred,
how many used EDI for the prescribing
Patient-Centered Measures include medication management metrics, synthesized from surveys of patients about their satisfaction related to medication management and communication by caregivers. The NQF-endorsed HCAHPS survey [NQF, 2005] addresses this through the following questions: “During this hospital stay, were you given any medicine you had not taken
before?” (Q.15); “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?” (Q.16); and “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?” (Q.17). Measures of patient participation in maintaining their medication lists may also be undertaken.
Settings of Care Considerations
Rural Healthcare Settings: All requirements of the practice are applicable to small and rural healthcare settings as specified.
Children's Healthcare Settings: All requirements of the practice are applicable to children’s healthcare settings as specified.
Specialty Healthcare Settings: All requirements of the practice are applicable to specialty healthcare settings as specified.
New Horizons and Areas for Research
It is critical that medication management systems
be better understood in order to leverage
products, services, and technologies that can
enable best practices to reduce preventable
harm to patients across the healthcare organization.
Research in the areas of enabling
technologies may hold promise. [Lesselroth,
2009] Evaluation of the improvement in medication
accuracy by actively communicating
with the patient’s community pharmacy for
medication verification and communication
of medication discharge lists should also be
included for further research. Evaluation of a
secure electronic medicine list to which the
patient may designate access by caregivers,
such as Google Health or HealthVault, could
be considered for future medication list access.
Other Relevant Safe Practices Relevant practices include Safe Practice 1: Leadership Structures and Systems; Safe Practice 4: Identification and Mitigation of Risks and Hazards; Safe Practice 12: Patient Care Information; and Safe Practice 15: Discharge Systems. Safe Practice 18: Pharmacist Leadership Structures and Systems is vitally important to a successful medication reconciliation program.
Background: Most examples of successful medication reconciliation
(MR) programs have reported on paper-based
systems, the most common of which is a standardized MR
form that often serves as a medication order form. An interdisciplinary
process was undertaken by Bellevue Hospital,
New York Ci...
Patients admitted to a hospital commonly receive new medications or have changes made to their existing medications. As a result, the new medication regimen prescribed at the time of discharge may inadvertently omit needed medications that patients have been receiving for some time. Alternatively, new medications...
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 in...
Despite improvements in health outcomes due to medication therapy, there is growing evidence that the frequent use of medications and especially multiple medications in chronically ill patients may lead to safety and quality problems. Performance measures that provide more targeted information about the process an...
Two out of every three patients who visit a doctor leave with at least one prescription for medication, leading to a record volume of nearly 3.4 billion prescriptions dispensed in 2005 alone. This is an increase of almost 60% since 1995. Two-thirds of the U.S. population receive at least one prescription per year,...
ConsumerMedSafety.org is brought to you by the Institute for Safe Medication Practices (ISMP)—the nation's only nonprofit organization of pharmacists, nurses, and doctors devoted entirely to safe medication practices. Preventing medication errors is no longer just a responsibility for health professionals—c...
The Massachusetts Coalition for the Prevention of Medical Errors is a public-private partnership whose mission is to improve patient safety and eliminate medical errors in Massachusetts.
The Coalition's membership includes consumer organizations, state agencies, hospitals, professional associations for phy...
My Medicine ListCan you name all of the medications you are taking? Do you know what doses you are taking and what the medicine is for?
“My Medicine List™” can help you keep track of everything you take to keep you healthy, including pills, vitamins, and herbs.
Having a list of all your medicines in one...
Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care...
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