SummaryMultidisciplinary teams at Forrest General Hospital developed and implemented a comprehensive package of interventions to improve the medication reconciliation process related to patient admissions, transfers, and discharge. With the help of outside consultants, these teams generated the ideas and educated and trained the entire staff on their implementation. The program significantly improved the medication reconciliation process, leading to a reduction in reconciliation-related errors.Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics related to the medication reconciliation program.
Developing OrganizationsForrest General Hospital
Forrest General Hospital is located in Hattiesburg, MS.
Date First Implemented2007
Problem AddressedMedication errors are an all too frequent occurrence in the U.S. health care system, with problems in the medication reconciliation process being a major cause of those errors. Medication errors injure at least 1.5 million Americans annually, costing the nation more than $3.5 billion a year.1 More than 350 medication errors resulting in death or major injury are in The Joint Commission's sentinel event database, with 63 percent related to breakdowns in communication, and approximately one-half of those would have been avoided through effective medication reconciliation.2
- Many sources of medication reconciliation problems: Safe medication management in the hospital setting is a complex task, with errors occurring due to a variety of factors, including but not limited to lack of patient knowledge regarding their medications; the involvement of multiple care providers, including primary care and specialists; and the use of multiple sources of medication lists for the same patient.
- No easy fixes: Although reducing medication errors related to medication reconciliation has been a Joint Commission improvement goal since 2005, many of the changes that hospitals are making are still in their early stages and have not yet been tested. Despite significant efforts, Forrest General Hospital recognized a continued need to improve care related to The Joint Commission's medication reconciliation goal.
Description of the Innovative ActivityForrest General Hospital uses multidisciplinary, cross-functional project teams to develop, implement, and train staff on a set of policies and processes designed to improve the medication reconciliation process and enhance patient safety. Key elements in the program include the following:
- Cross-functional project teams that meet periodically to set and promote adherence to goals: Three multidisciplinary cross-functional teams were formed—one to focus on admissions, one on transfers, and one on discharge. Teams initially met weekly for a period of 6 weeks, then moved to monthly sessions, and now meet as needed. Team members include pharmacists, physicians, nurses, respiratory therapists, and representatives of other departments such as emergency, education, information technology, and quality improvement. Using the seven-step change acceleration process model, each team sets goals and identifies specific opportunities to improve medication reconciliation at each of the key points in the process. Project goals, along with selected examples of specific policies or programs to reach these goals, are detailed below:
- Decrease number of medications that have not been reconciled: The team built documentation capabilities into the electronic medical record (EMR) so that emergency department (ED) nurses could begin to assess medications that the patient takes at home.
- Increase use of "physician's order to resume home medications" form: The team separated the home medication assessment from the admission assessment in the EMR to allow nurses to complete the home medication assessment quickly and print the orders for physician use in a timely manner, rather than having to wait until completing the entire history and nursing assessment.
- Implement use of "transfer reconciliation order" form: The team implemented a rapid cycle improvement process led by intensivists and one registered nurse in the intensive care unit to test the use of transfer orders; the team also built transfer orders that print automatically from the EMR.
- Increase use of the "medication reconciliation discharge" form: The president of the medical staff worked one-on-one with obstetric physicians and surgeons to increase use of this form.
- Decrease medication transcription errors at discharge: Nurses were taught a standardized approach for transcribing medications from the orders into the discharge instructions, including how to place information on over-the-counter medications in the instructions.
- Initial intensive training on new policies and processes to meet the goals: After the first 6 weeks of team meetings, two all-day training sessions were held to educate 455 nurses and unit secretaries (across 19 inpatient units) on the new programs and policies that the teams developed. Each participant spent approximately 20 minutes at each of three separate training booths, which were organized around the priority areas—admission, transfer, and discharge. ED staff received separate training, while physicians received one-on-one training sessions during departmental meetings. In addition, training packets were developed and distributed to each unit in the hospital as reference material. New employees and physicians were trained on the revised medication reconciliation processes as a part of their respective orientation programs.
- Ongoing training and education: Ongoing education typically takes the form of written user alerts that are distributed to appropriate clinical staff. These alerts outline enhancements made to the EMR.
- Revised hospital policies: Key changes in the medication reconciliation process were incorporated into formal hospital policy, including policies related to copying doctor's orders and the transfer of doctor's orders for surgical patients.
- Monthly performance report: To stimulate continuous improvement, performance data on progress against the key goals highlighted above are shared monthly with the steering committee, project team, medical staff, and patient care managers.
- Celebration and promotion of successes: To foster momentum and continuous improvement, the hospital routinely celebrates and promotes successes related to the program. For example, a celebration luncheon was held for the project teams, and team members showed their appreciation to staff by bringing banners, balloons, and flowers to the main pilot units and ancillary departments. In addition, all staff members who participate in training receive letters of appreciation. Articles highlighting the program's accomplishments are routinely printed in hospital and physician newsletters.
References/Related ArticlesGeorgia K, Kinney K, Pace A, et al. Ensuring medication reconciliation. Patient Saf Qual Healthcare. 2007 Nov/Dec. Available at: http://www.psqh.com/novdec07/medication.html
Contact the InnovatorAngela Pace, RN, MSN, CPHQ
Director of Quality Improvement
Forrest General Hospital
PO Box 16389
Hattiesburg, MS 39404-6389
Innovator DisclosuresMs. Pace has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsA pre- and post-implementation comparison on key program metrics shows that the program significantly improved the medication reconciliation process, leading to reductions in the number of medication errors.
Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics related to the medication reconciliation program.
- Improved documentation: ED medication documentation reached 76 percent; no pre-implementation data are available, because there was no process for this documentation in place. The overall percentage of unreconciled medications fell from 29 to 6 percent.
- Increased use of forms and tools that support the process: Use of the medication reconciliation discharge form became nearly universal, increasing from 71.5 to 98 percent. Use of the transfer reconciliation order form reached 67 percent; this form did not exist before the program was put in place. Use of the physician's order to resume home medications form increased from 37 to 96 percent.
- Medication reconciliation transcription errors decreased: Home medication assessment completeness improved significantly after implementation of the program, with the number of pharmacy interventions per patient assessment falling from 1.9 before the program to 1 following program implementation.
Context of the InnovationForrest General is a 512-bed, level II regional trauma center hospital system with 2,500 full-time employees, 26,000 admissions, and 85,000 ED visits annually. The impetus for Forrest General to embark on this program was the development of The Joint Commission's National Safety Patient Goal (#8). It calls for accurate and complete reconciliation of medications across the continuum of care. This includes development of a process for comparing the patient's current medications with those ordered while the patient is under the care of the organization and communication of all medications to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care, both within and outside the organization (including providing the patient with a complete medication list on discharge to the home).
Planning and Development ProcessKey steps in the planning and development process include the following:
- Hiring an outside consultant: This consultant provided guidance in assessing the current medication reconciliation process and assisted the teams over a 6-week period in developing a comprehensive bundle of interventions to improve it.
- Adapting the seven-step change acceleration process model to guide the teams: This model includes the following steps—leading change, creating a shared need, shaping a vision, mobilizing commitment, making change last, monitoring progress, and changing systems and structures.
- Forming a steering committee: The Forrest General Hospital steering committee consisted of the president of the organization, the vice president of medical affairs (a physician), the vice president of clinical operations (who is also the chief nursing officer), the president of the medical staff, the project leader, and the three subteam leaders from the admission, transfer, and discharge teams. This executive committee provided crucial leadership support throughout the project.
Resources Used and Skills Needed
- Personnel: No additional personnel are necessary for the program, which is staffed by existing employees as a part of their regular duties.
- Costs: The costs of the program are minimal, consisting primarily of fees charged by the outside consultants.
Funding SourcesThe program was funded internally by Forrest General Hospital.
Getting Started with This Innovation
- Create an executive steering committee: Identify key hospital leaders to form steering committee.
- Conduct a stakeholder analysis: Identify attitudes about, facilitators of, and barriers to the current medication reconciliation process.
- Identify program and unit champions: Recruit individuals who are interested in improving the process and who have influence over other stakeholders to serve as champions for the program. Key unit champions were important in gaining physician support and acceptance of the process.
- Form diverse teams: Include representation from as many areas of the hospital as possible, including information technology. Each department has valuable input and perspectives to offer on the medication reconciliation process.
Sustaining This Innovation
- Celebrate and promote successes: Provide rewards and recognition to the health care team members and the general staff for program accomplishments.
- Monitor outcomes: Continually monitor project outcomes and address issues as needed.
1 Institute of Medicine. Preventing Medication Errors. Washington, DC: The National Academies Press; 2007.
2 Joint Commission International Center for Patient Safety. Using medication reconciliation to prevent errors. 2006 Jan 25; Issue 35.
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Service Delivery Innovation Profile
Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 13, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 04, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.