Institute for Healthcare Improvement: Medication Reconciliation Guidelines and Home Medication List

The guidelines developed at Luther Midelfort Hospital describe a process for completing medication reconciliation within 24 hours of admission. Staff use the Home Medication List to create a list of patient medications taken prior to hospitalization and compare it with a list of medications ordered on admission. All discrepancies between the two lists are then resolved within 24 hours by the admitting physician who may delegate the responsibility by writing an order on the physician order sheet that identifies the reviewing physician or non-physician provider who is credentialed to write orders.

The Home Medication List and reconciliation guidelines help ensure that there are no home medications unintentionally omitted or inappropriately continued during a patient's hospitalization.

Background

Luther Midelfort has been doing medication reconciliation since 1999. Since then we have reviewed our previous process, found opportunities for improvement, and began a new process in June 2005. Changes made include:

One form, called the “The Home Medication List,” for all patients and one process for all patients and nursing units.
To avoid duplication of effort, staff add new information to a patient’s Home Medication List when it is first received, which can be passed on to inpatient staff to complete.
To reduce errors, redundancy is built into the two components of medication reconciliation: the creation of the Home Medication List and the comparing of that list to written orders.
The Home Medication List contains not only how medications are prescribed, but also how patients are actually taking the prescribed medications, in addition to medications taken regularly but not prescribed.
The Home Medication List is not used as an order sheet.
Physicians are required to verify admission reconciliation by reviewing and signing the reconciled Home Medication List with 24 hours of a patient’s admission. Pharmacists review and sign the form after physicians sign it.

What We Have Learned

Redundancy is necessary to minimize errors.
Non-medical physicians specialists may be uncomfortable with medication management and may need to be encouraged to obtain medical consultation.
The time required of nursing and pharmacy is considerable.
Increased physician involvement improves nursing and pharmacy acceptance of the process.
Medication reconciliation has to be a team effort.

Directions

This tool consists of a downloadable ZIP file containing two items:

Documentation Guidelines for Home Medication Reconciliation List and Admission Medication Reconciliation
Home Medication List

Use these guidelines and home medication form as a reference when implementing or improving your own medication reconciliation processes.

**Please note that the file is in ZIP format, and contains two files. Windows XP will automatically open the ZIP file; for other operating systems a tool like WinZip (or other free alternatives) should be used.