This story originally appeared in IHI's 2007 Annual Progress Report.
“We are so jazzed about this, it’s like someone invented the wheel,” says Steven Tremain, MD, ABFP, FACPE, Director of System Redesign at Contra Costa Regional Medical Center in Martinez, CA. Tremain is talking about the hospital’s new systems for reconciling patients’ medications at admission
, transfer and discharge as part of a broader initiative to redesign processes to improve reliability.
“In the old process, the physician and nurse would each make a list of the patient’s medications. Then the doctor would write medication orders on a third sheet. The three sheets were never cross-checked, so there was no way to know if a medication missing from the orders was overlooked or intentionally discontinued.”
Now, a single form — one that went through many iterations in small tests of change — replaces the three old sheets. The physician indicates for each medication whether it should be continued, modified, or discontinued. It goes to the pharmacy, and the nurse reviews it for accuracy with the patient.
“This has been the most meaningful work I’ve done professionally,” says Tremain. “We can often see how ridiculous some of our processes are, but we are fighting today’s battles and don’t often have the time or tools to fight and win tomorrow’s. Without the tools and collaboration through IHI, we’d still be struggling.”