Paddy Macken, MD, member of Pharmacy and Therapeutics Committee
Jane Justesen, RN
Ron Hitzke, RPh, Pharmacy Director
Mona Howard, RN, Front-line Nurse
Roger Resar, MD, Agent of Tremendous Change and Global Innovation Seeker

Decrease the number of adverse drug events (ADEs) and potential ADEs by 60 percent on the Telemetry/Intermediate Care Unit

• Discrepancies from unreconciled medications per 100 admissions (potential ADEs)
• ADEs per week (actual ADEs)

When we reviewed our patient records, our team found that medications not reconciled at transition points may account for as many as 50 percent of all medication errors and up to 20 percent of ADEs seen both in the hospital and in later outpatient settings. This was a powerful incentive for us to improve the process of reconciling medications.

• Developed a tool for reconciling medications at admission, identifying discrepancies and capturing documentation that reduced the need for nurses and pharmacists to contact physicians for clarification.
• Redesigned the discharge process with new forms that require a review for reconciliation of medications to ensure that patients left with accurate discharge instructions and medication orders.
• Required a reconciliation review of each patient’s Medication Administration Record (MAR) during transfer between patient care units, to ensure medications were not inadvertently omitted.
• Recruited a team to redesign (i.e., error-proof) our MAR form.
• Set up a quality audit of the reconciliation review process and data reporting procedures.
• Started performing medication reconciliation during admissions to the Critical Care Unit.

Implementing a system to ensure that medication orders were reconciled really helped us improve our processes and reduce both potential and actual ADEs and exceed our aim. This was by adding reconciliation at all transition points — admission, transfer and discharge — as we would not have the same amount of success if we had not improved all three.

• Start with small, incremental tests of change. They are the only way to undertake a project of this size in your organization.
• Include all members of the patient care team in the process of medication reconciliation. No single group — nurses, pharmacists or physicians — should be responsible for ensuring that it works.
• Involve members of the staff and medical education departments early in the change process as they can help develop the tools to sustain the process with new staff and providers.
• Measure and report your results, which makes sustaining and expanding the project possible.

Roger Resar, MD
resar.roger@mayo.edu