Medication reconciliation at an academic medical center: Implementation of a comprehensive program from admission to discharge

PURPOSE: The implementation of a comprehensive medication reconciliation program to reduce errors in admission and discharge medication orders at an academic medical center is described. SUMMARY: A multidisciplinary team was formed to assess the current process of obtaining medication histories and to develop a new workflow for the pharmacist to obtain and reconcile medication histories. Pharmacists received intensive training on the new workflow, policies, and procedures. Hospitalwide multidisciplinary education was provided, and the new process was introduced in November 2005. Every inpatient admitted to the hospital has a complete and comprehensive home medication history interview conducted by a pharmacist or designee (pharmacy student or intern with subsequent verification by a pharmacist) within 24 hours of arrival. All components of the medication history are documented utilizing an integrated electronic medical record (EMR) medication documentation tool. Development of the discharge medication reconciliation program began in fall 2006. A discharge medication reconciliation report form was created through the EMR to improve the accuracy of the discharge medication orders. The form provides physicians with complete, accurate medication information and decreases the risk for transcription errors. Finally, a discharge medication report was developed for patients to take home. Analysis of the discharge reconciliation process revealed that medication errors were reduced from 90% to 47% on the surgical unit (95% confidence interval CI, 42-53%; p = 0.000) and from 57% to 33% on the medicine unit (95% CI, 28-38%; p = 0.000). CONCLUSION: A pharmacy-driven multidisciplinary admission history and medication reconciliation process has reduced medication errors in an academic medical center.