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 in the hospital and up to 20 percent of adverse drug events (ADEs). Each time a patient moves from one setting to another, clinicians should compare previous medication orders with 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. Organizations can evaluate how well their own processes work by collecting data on the number of errors that occur due to lack of reconciliation. This data helps establish a baseline or errors due to unreconciled medications, thereby supporting the argument to improve, or in some cases to create, a full-scale medication reconciliation process. Teams can track data over time to demonstrate improvement in reconciliation processes.

Formula: The total number of errors related to unreconciled medications found in a sample of patient records, divided by the total number of patient records reviewed. Multiply the result by 100.

Decrease the number of errors related to unreconciled medications by 75 percent in 1 year.

Every month, select a random sample of closed patient records, each with a minimum stay of 3 days. The monthly review should include a minimum of 20 charts (even better would be a weekly review of 10 records). Report data as a monthly number of errors per 100 admissions. Using the instructions in the Medication Reconciliation Review, review the charts for errors related to unreconciled medications.