Assessment & Process Evaluation
Now that medication reconciliation has been implemented at your organization, it is time to assess the process.
Immediately after implementation, auditing is critical to assess adoption. Auditing should be done at all the transitions of care and should include each discipline involved in the process. For example, if physicians and nurses are responsible for medication reconciliation at your organization, it is necessary to look at overall compliance as well as the individual disciplines’ compliance. Knowing how each discipline is performing will help tailor feedback to leadership and identify discipline specific issues that need to be addressed.
Depending on resources available at your organization, there are various ways auditing can be accomplished. Audits can be conducted electronically or manually. They can be done prospectively or retrospectively. Some audits address quantity while others address quality; it is important to look at both. The quantity audit gives insight to adoption and adherence to your defined process. The quality audit shows the impact on patient safety, such as potential harm avoided through reconciliation.
Comparison of Auditing Techniques (PDF)
A. Example of Metrics and Auditing Tools
1. Examples of Metrics on Admission: Illinois Hospital Association (IHA) Medication Reconciliation Collaborative
Through their medication reconciliation state-wide collaborative, the IHA developed the following three measurements for medication reconciliation compliance. The first measure identifies the percent of patients that have a home medication list documented in the medical record using the correct tool for documentation. The second measure identifies the percent of individual home medications that have been reconciled with admission orders. The third measure identifies the percent of patient records with all medications reconciled. The same concepts used for these measures can also be applied to transfer and discharge.
IHA Medication Reconciliation Measurements (PDF)
2. Examples of Manual Audit Tools
Below are 2 sample audit tools that can by utilized when performing a manual audit for medication reconciliation.
Data Collection Tool (PDF) - used for evaluation of medication reconciliation's impact on patient safety or for conducting research related to medicati
B. Reporting Audit Results
In addition to performing the audits, results will need to be communicated. The table below is an example of how to display medication reconciliation audit results for a given day. Depending on the size of your organization, the number of charts reviewed may vary.
| Issue | Compliance Defined as: | Current Compliance as of [insert date] | Action Plan |
| Medication Reconciliation on Admission | Numerator: # of patients with a home medication list documented and reconciled at admission Denominator: # of patients admitted |
GOAL: >90%
ACTUAL: [insert current compliance] |
Insert plans to close the gap between the actual compliance percentage and the goal |
| Medication Reconciliation on Transfer | Numerator: # of patients with medications reconciled upon transfer Denominator: # of patients transferred |
GOAL: >90%
ACTUAL: [insert current compliance] |
Insert plans to close the gap between the actual compliance percentage and the goal |
| Medication List at Discharge | Numerator: # of patients provided an updated home medication list at discharge Denominator: # of patients discharged |
GOAL: >90%
ACTUAL: [insert current compliance] |
Insert plans to close the gap between the actual compliance percentage and the goal |
C. Post-Implementation Strategies to Increase and Sustain Compliance
Audits will help identify areas with low compliance. It will be important to understand the root cause (i.e. knowledge deficit, lack of training, no buy-in) to tailor improvement strategies. Examples of improvement strategies for medication reconciliation that will be highlighted in the following section include: (1) identifying and addressing barriers for low compliance, (2) focus groups, and (3) medication reconciliation road show.
1. Identifying Challenges and Addressing Barriers
It will be helpful to outline challenges faced during implementation and actions that have been or will be taken to address each challenge. The table below is a template that can be utilized to clearly list each challenge, observations associated with the challenge, a proposed action and the next steps or responsible party for follow-up. This will keep you and/or the medication reconciliation leadership team updated on the progress of each identified road block to effective medication reconciliation.
| Implementation Challenges | Observations | Proposed Action | Next Steps/Primary Responsibility |
| Example: Reliance on memory; lack forcing function | Physicians are not remembering to place a medication reconciliation order | Design a prompt during the admission ordering phase that creates a forcing function for physicians to complete the medication reconciliation form | Monitor physician compliance for completing the medication reconciliation form |
2. Focus Groups
During monitoring efforts, if you identify certain areas or disciplines with low adherence to the process, it may be necessary to circle back to front-line staff to find out what is working and what is not working. By proactively seeking this information, it will decrease the amount of frustration the front-line staff is feeling about the newly implemented medication reconciliation process. For more information about focus groups and how to facilitate one refer to the Designing Your Process section of the toolkit.
3. Medication Reconciliation Road Show
If physician compliance is a troubling issue, consider taking medication reconciliation on the road. Similar to the concept of executive walk rounds, having physician leadership on the floors talking to front-line staff about the importance of medication reconciliation is a way to help increase compliance. To get a road show started, it is a good idea to provide leadership with examples of close calls your organization has had with medication reconciliation. By leadership telling the story to front-line staff of potentially harmful situations related to medication reconciliation, it may help reinforce the need. The objectives of the Road Show are:
- Create a clear level of accountability for performing medication reconciliation
- Emphasize the new medication reconciliation process is NOT optional
- Reinforce the importance of obtaining a complete and accurate medication history, documenting the medication history in the appropriate place in the medical record, and facilitating a thorough transfer and discharge process across the continuum of care
- Obtain feedback from frontline staff to learn what is perceived as obstacles to performing medication reconciliation
- Assess the impact that medication reconciliation is having on patient safety of each identified road block to effective medication reconciliation.
D. Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
NCC MERP developed categories for classifying medication errors. This index considers factors such as whether the error reached the patient and, if the patient was harmed, to what degree. The Council encourages the use of its index in all health care delivery settings and by researchers and vendors of medication error tracking software. The table below explains the different categories of medication error classification.
Different categories of medication error classification were adapted into the table below. Examples of medication reconciliation errors are included to illustrate how this index can be used to classify each example based on the NCC MERP index. For more information about the classification of medication errors visit http://www.nccmerp.org.
| Category | Description | Example |
| A | No error, capacity to cause error | NA |
| B | Error that did not reach the patient | NA |
| C | Error that reached patient but unlikely to cause harm (omissions considered to reach patient) | Multivitamin was not ordered on admission |
| D | Error that reached the patient and could have necessitated monitoring and/or intervention to preclude harm | Regular release metoprolol was ordered for patient instead of extended-release |
| E | Error that could have caused temporary harm | Blood pressure medication was inadvertently omitted from the orders |
| F | Error that could have caused temporary harm requiring initial or prolonged hospitalization | Anticoagulant, such as warfarin, was ordered daily when the patient takes it every other day |
| G | Error that could have resulted in permanent harm | Immunosuppressant medication was unintentionally ordered at one-fourth the dose |
| H | Error that could have necessitated intervention to sustain life | Anticonvulsant therapy was inadvertently omitted |
| I | Error that could have resulted in death | Beta-blocker was not reordered post-operatively |
Lessons Learned
- Electronic audits are an easy and efficient way to show adherence to the medication reconciliation process
- Manual audits are time consuming but help identify the quality of the medication reconciliation process and the potential impact on patient safety
- Prospective audits are ideal for medication reconciliation since interventions can be made if medication reconciliation was not done appropriately
- Post-implementation, medication reconciliation audits should be performed and communicated often
- Feedback should be communicated to senior leadership, to all management levels and to front-line staff