Table 1.
A. First Steps for Success: Preparation and Site Assessment | Examples |
---|---|
Review of Basic Quality Improvement Principles Additional materials available in Appendix (1, 2) |
▪ Start preimplementation planning ▪ Clarify key stakeholders ▪ Obtain institutional support |
Define Steps of Medication Reconciliation process | ▪ Take BPMH on admission ▪ Reconcile BPMH with admission orders ▪ At time of transfer or discharge, reconcile BPMH and current medication orders ▪ At discharge, provide discharge medication counseling to the patient and an accurate medication list to patient/caregiver ▪ At discharge, communicate medication list with outpatient provider |
Brief Literature Review | ▪ Referenced† |
Assemble Team and Develop a Strategy | ▪ Identify team members, including team leader, QI team facilitator, etc. ▪ Map current medication reconciliation process, perform gap analysis ▪ Create specific, measurable goals |
B. Intervention Components | Examples |
I. Assigning Roles and Responsibilities | ▪ Identify resources available for each person to complete task ▪ Outline required knowledge, skills, and behaviors for person performing each med reconciliation step ▪ Encourage ideal use of personnel to increase efficiency ▪ Assign “ownership” for the overall medication reconciliation process |
II. Improve Access to Preadmission Medication Sources | ▪ Empower patients/caregivers to own medication list ▪ Improve skills of inpatient medication history-takers ▪ Improve IT access to sources of medication information |
III. Patient-Owned Medication Lists Additional materials available in Appendix 4 |
▪ Provide patient with templated medication list on discharge ▪ Provide patients with medication lists in the ambulatory setting to support admission list creation |
IV. Guidelines for Taking a BPMH Instructional video available Additional materials available in Appendix (3, 4) |
▪ Use at least two different sources of information in compiling BPMH (for example, patient, medication list, pharmacy, etc.) ▪ Resolve any discrepancies between sources ▪ Use probing questions |
V. Discharge Counseling Instructional video available Additional materials available in Appendix (4) |
▪ Correctly identify the “active learner” ▪ Review the entire medication list, including new meds, changes and discontinued meds, instructions, and potential side effects ▪ Use the “teach-back” technique |
VI. Risk Stratification | ▪ Stratify patients into high vs. low-intermediate risk based on patient characteristics (for example, number of preadmission medications, etc.) such that high-risk patients receive additional resources (see VII.) |
VII. Use of Medication Reconciliation Bundle Additional materials available in Appendix (6, 7) |
▪ Ensure that high-risk patients have medication histories obtained from and medication counseling performed by the most highly skilled personnel with time and resources to perform an “intensive” medication reconciliation bundle |
VIII. Application of IT, Ideal Features Additional materials available in Appendix (7) |
▪ Increase access to sources of preadmission medication information ▪ Facilitate comparison and reconciliation of medication lists |
IX. Phased Implementation | ▪ Phase in interventions by location or service, patient risk, or component |
X. Social Marketing/Engagement of Community Additional materials available in Appendix (8) |
▪ Determine target audience (for example, inpatient or outpatient providers, patients) |
C. Appendix (Supplemental Material) | Examples |
1. Making Business Case for Medication Reconciliation | ▪ Demonstrate potential for return on investment |
2. MARQUIS Institutional Site Assessment | ▪ Assess institutional support ▪ Assess existence of on-site study pharmacist ▪ Assess policies and procedures for medication reconciliation |
3. Best Possible Medication History (BPMH) Toolkit | ▪ Case for role-play |
4. Patient-Friendly Discharge Material | ▪ Examples provided |
5. Patient-Owned Medication Lists | ▪ Adopt a medication template, provide patient/caregiver with template on discharge |
6. Paper Medication Reconciliation Forms | ▪ Examples provided |
7. Vendors of Electronic Medication Reconciliation Products | ▪ Examples provided |
8. Social Marketing Materials | ▪ Examples provided |
Appendices refer to those available with the implementation manual at Society of Hospital Medicine. Overview: Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS). Accessed Jun 27, 2013. http://www.hospitalmedicine.org/MARQUIS. BPMH, best possible medication history; QI, quality improvement; IT, information technology.
Mueller SK, et al. Hospital-based medication reconciliation practices: A systematic review. Arch Intern Med. 2012 Jul 23;172(14):1057–1069.