University of Massachusetts Memorial Medical Center Has 95 Percent of Patients’ Hospital Medical Records Free of Medication Reconciliation Errors

This story originally appeared in IHI's 2007 Annual Progress Report.


Eric Alper, MD, was Patient Safety Officer at UMass Memorial Medical Center in Worcester, Massachusetts, at the time when medication reconciliation first became a major focus. He says that the effort to make sure information about a patient’s medications is accurate when they are admitted, transferred, and discharged is not just another project because it changes the fabric of the organization, including processes, roles and responsibilities.

“Medication reconciliation requires logistical and cultural change, and repeated process redesign at multiple levels,” he says, “which is why leadership is so important.” Alper says the Center’s CEO and chief quality officer strongly supported the effort.
At UMass, the process was streamlined through the introduction of a new form that combines the medication list and the order sheet, eliminating the need to copy information from one to the other. Residents were given primary responsibility for reconciling medications, solving a medication reconciliation problem that is common in hospitals: knowing whose job it is. According to Chief Quality Officer Robert Klugman, MD, the effort has paid off: up to 90 percent of patients have a medication reconciliation form in their chart, and 95 percent of patients’ hospital medical records are free of reconciliation errors.

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