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Medication Reconciliation. Tools, Keys and Tips. June 3, 2009 Steven Tremain, MD, FACPE, Convergence Health Consulting Chief Medical Officer & Chief Medical Information Officer Contra Costa Regional Medical Center. Session Objectives. Medication Reconciliation… How  the approach

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medication reconciliation

Medication Reconciliation

Tools, Keys and Tips

June 3, 2009

Steven Tremain, MD, FACPE, Convergence Health Consulting

Chief Medical Officer & Chief Medical Information Officer

Contra Costa Regional Medical Center

session objectives
Session Objectives

Medication Reconciliation…

  • How the approach
  • What  the process
  • Tools  the forms
  • Keys to success
  • Tips  take home advice




medication reconciliation one patient s story
Medication Reconciliation……One Patient’s Story
  • While an inpatient, an elderly woman was started on the new anti-hypertensive drug.
  • She was discharged with a new RX for blood pressure medicine.
  • After discharge, the woman was seen in one of the hospital’s ambulatory care clinics complaining of severe dizziness.
  • Her PCP figured out that she was taking the blood pressure medicine prescribed in the hospital on top of an earlier prescription she’d been using at home for the same thing.
key 1
Key #1

Find and tell the stories….

….They exist

….They’re powerful

….They’ll engage people

contra costa regional medical center health centers
Contra Costa Regional Medical Center & Health Centers



San Francisco

Bay Area

about ccrmc
  • County hospital with 141 staffed beds
  • 8 owned & operated health centers
  • Family Practice residents
  • EMR in ED only
  • Hospital & clinics still using paper records
  • Meditech clinical system (incl pharmacy)
ccrmc s recognition
CCRMC’s Recognition
  • IHI Mentor Hospital since 2006
  • IHI Innovation Award Winner (Dec 2007)
  • Agency for Healthcare Research & Quality (AHRQ) Innovation Exchange (
  • Published case study in Joint Commission Resources’ Medication Reconciliation Toolkit for Implementing NPSG 8

Improve Medication Safety

Reduce rates of unreconciled medications

Implement an effective admission, discharge and transfer reconciliation process

Model for Improvement Source: Institute for Healthcare Improvement (IHI)

tip 1
Tip #1

Segment pieces of the improvement process in bite size increments.

  • Allows for small scale tests of change
  • Allows for customization where necessary
  • Improves likelihood of success
our mr project team
Our MR Project Team
  • Physician champion (Internist)
  • Resident
  • Nursing champion (Medicine unit staff RN)
  • Pharmacists (2) Pharmacy Tech (1)
  • Clinical Informaticist (RN)
  • Forms expert
  • Nursing rep for every service
  • MD rep for every service
  • Leader
key 2
Key #2

Multi-disciplinary team

  • Physician champion essential
  • Typically, pharmacy, nursing and medical staff
  • Best to have a strong leader, not aligned with primary disciplines
tip 2
Tip #2

Short (45 minutes) weekly team meetings

  • Maintains momentum
  • Promotes engagement

Outcome Measures

  • % unreconciled meds (Goal = 0%)
  • % of patients with ALL meds reconciled (Goal = 100%)

Process Measure

  • % Compliance with use of the forms/process (Goal = 100%)
  • We’ve reduced our rates of unreconciled home medications…

…from 26% to 1% on ADMISSION

…from 23% to 4% on DISCHARGE

  • We’ve reduced our rates of unreconciled medications…

…from 12% to 4% on TRANSFER

  • Improvement has been sustained for 3 years.
tip 3
Tip #3

Test measurement tool thoroughly

  • insures that the data collection process will produce the information you are seeking
tip 4
Tip #4

“Measurement is for learning, not for judgment”

“Use data to generate light not heat!”

  • Use data to learn where your process is failing
  • Data collection should be frequent, small samples
admission reconciliation
Admission Reconciliation
  • Paper process
  • Originally: Admitting provider hand-wrote the list of medications patient was taking at home on AMROF, which doubles as an admission order form.
  • Now: Admitting provider prints an eAMROF form which is pre-populated with the current med list and uses same form to order medications on admission.
  • Process being used 99% of the time.
key 3
Key #3

Use “What’s-In-It-For-Me” (WIFM) approach in workflow design

  • Admitting MD  new process was less work (med list doubles as an order form)
  • Admitting MD  eAMROF was less work (pre-populated list meant less writing)
  • Admitting RN  new process was less work (stopped capturing a med list from scratch)
key 4
Key #4

Customize where necessary; Standardize where possible

  • Allows for unique workflows
  • Promotes buy-in from staff

Examples  Peds, OB

key 5
Key #5

Make it easy for staff to use the new process & difficult or impossible to use the old process

  • Key for achieving high compliance with use of the process

Example  Attached Admission Med Rec form as page 1 of all admit order forms already in use (manual at first then via forms vendor)

transfer reconciliation
Transfer Reconciliation
  • Electronically printed form contains list of all active meds as of that moment in time.
  • Provider uses form to order medications on transfer within the facility.
  • Process being used 99% of the time.
key 2 6
Key #2 & #6

Use “What’s-In-It-For-Me” (WIFM) approach in workflow design

  • Receiving RN  Less work (no more “continue previous meds)

Harness Informal Champions

  • Receiving RN  Constant reminders to physicians who didn’t use the new process
discharge reconciliation
Discharge Reconciliation
  • Electronically printed form contains list of all pre-admit meds and active inpatient meds as of discharge.
  • Provider uses form to order discharge meds
  • Patient is provided with a “patient friendly” list of discharge medications.
  • Copy of list is sent to next provider of care.
key 3 5
Key #3 & #5

Use “What’s-In-It-For-Me” (WIFM) approach in workflow design

  • Discharging MD  Less work (home & inpatient meds print on a report)
  • Patient  Now has a concise med list

Make it easy for staff to use the new process & difficult or impossible to use the old process

Example  Stamp on old forms

discharge reconciliation who does what
Discharge Reconciliation:Who Does What…….
  • MD
    • Review and sign the DMROF. Update RXM as needed
    • Generate needed prescriptions in RXM
    • Print Patient Home Medicine List from RXM (aka Patient Friendly Med List)
    • Complete the STOP medication section on the Med List
discharge reconciliation who does what36
Discharge Reconciliation:Who Does What…….
  • Nursing Staff
    • Review Patient Home Medicine List with patient (aka Pt Friendly), make a copy for the chart.
    • Indicate on Patient Home Medicine List, the time the next dose of any medication is due.
    • Write Patient Home Medicine list if not generated from RXM
discharge reconciliation who does what37
Discharge Reconciliation:Who Does What…….
  • Clerk
    • Fax prescriptions to outside pharmacy
key 7
Key #7

Identify & Mitigate Failures

  • Admission reconciliation failure causes discharge reconciliation failure
  • Develop workflows to identify key failure points so they can be fixed immediately

Example  Daily report in Pharmacy for identifying admitted patients w/o AMROF

preventing readmissions
Preventing Readmissions
  • Focus on CHF
  • Using LEAN/Kaizen
  • IS NOT: hospital ‘project’
  • IS: system way of functioning
  • Goal: using best practices for rapid adaption/adoption in our system
  • Template for other conditions
  • Bonus: close collaboration across “silos”
our approach
Our Approach
  • Bundle of 5 triggered at Dx
    • CHF order set
    • Patient education process
    • Interdiscpilinary teaching plan
    • Discharge appts made at time of admission!
    • CHF Discharge Nurse
chf discharge nurse
CHF Discharge Nurse
  • Twice weekly phone calls to patients
    • First call within 72 hours of discharge
  • Real time ongoing medication reconciliation of all meds
  • Education
  • Transportation assistance
  • Triage

CHF Nurse

  • Ask the patient: Since leaving the hospital.
  • How is your breathing?

Do you have worsening chest pain?

Can you lay flat without shortness of breath?

Are you coughing more?

Have you gained weight? If yes, how many pounds

Are you more dizzy or light headed?

  • Green Zone
  • All Clear – This zone is your goal. Your systems are under control
  • You have
  • No shortness of breath.
  • No weight gain more than 2 pounds (It may change 1 or 2 pounds).
  • No swelling of your feet, ankles, legs or stomach.
  • No chest pain.
  • Yellow Zone
  • Caution: - This zone is a warning.
  • You have a weight gain of 3 pounds or more in 1 day or a weight gain of 5 pounds or more in 1 week.
  • More shortness of breath.
  • More swelling or your feet, ankles, legs, or stomach.
  • Feeling more tired. No energy.
  • Worsening cough.
  • Dizziness.
  • Feeling uneasy, you know something is not right.
  • It is harder for you to breathe when lying down. You need to sleep sitting up in a chair.
  • Go to the emergency room or call 911 if you have any of the following:
  • Struggling to breath. Unrelieved shortness of breath while sitting still.
  • Have chest pain that is different or stronger than normal or usual.
  • Have confusion or can’t think clearly.


  • Congestive Heart Failure (CHF) Nurse Tool
  • CHF Nurse
  • Call all new CHF referrals received by fax twice a week on Tuesday and Friday:
  • Assess Clinical Condition (see attached):
  • Red Zone
  •  Advised patient to go to ED and Notified ED (370-5973)
  • Yellow Zone
  •  Made appointment within 24 hours ---- OR---
  •  Do green zone assessment below and call medicine dept. on call MD to consult.
  • Green Zone – Initiate discussion with patient or caretaker
  • Ask patient “teach back” questions:
    • What gain is concerning enough that you should report to your doctor?
    • What foods should you avoid?
    • Do you know what symptoms to report to your doctor?
  • Review medications:
    • “Were you able to get prescribed medications after you left the hospital?”
    • “Do you have the list of medicines they gave you when you left the hospital?”
    • “What is the name of your water pill(s)?”
    • Does patient have medications?  Yes  No
  •  Medications Refaxed /called to __________________________ pharmacy
  • Does patient administer own medications?  Yes  No
    • Medications reviewed with patient/family member_____________
  • Reinforced “Daily Activities” (daily wt., law-salt diet, activity as tolerated)
  • Review Appointment(s):
  •  Patient/family member aware of follow-up appointment(s) __________________________________
  • __________________________________________________________________________________
  •  Referral made to Social Worker (925)370-5480 for transportation issues.
  •  Appointment with Patient Educator made (next available):___________________________________
  • Other Intervention: _________________________________________________________________________________________________________________
  • Follow up:
  •  Low Risk Patient: Chart check to make sure patient made follow-up appt.
  •  High risk Patient (any patient requiring consultation with MD or not clear on any items on patient assessment): Chart check for repeat phone call 3 to 5 days.


Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on


Agency for Healthcare Research and Quality (AHRQ)


contact information
Contact Information