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Designing the Process

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Many organizations are uncertain about how to proceed with designing a workable solution for medication reconciliation. This section provides helpful information and tools for designing a new process or redesigning an existing medication reconciliation process including:

  • Guiding principles for process design/redesign
  • Determining roles and responsibilities for medication reconciliation
  • Considerations for various practice settings
  • Examples for electronic, paper-based or hybrid (electronic plus paper-based) systems
  • Methods for pilot testing prior to full scale implementation

A. Essential Principles for Designing a Successful Medication Reconciliation Process

These guiding principles should be considered as you design your medication reconciliation process:

  • Develop a single medication list, shared by all disciplines ("one source of truth") for documenting the patient's current medications. This list should be centrally located and easily visible within the patient's medical record.
  • Clearly define roles and responsibilities for each discipline involved in medication reconciliation.
  • Standardize and simplify the medication reconciliation process throughout your organization, and eliminate unnecessary redundancies. Recognize and understand nuances that may exist within various practice settings. Modify these nuances, as appropriate, to minimize variations, and then integrate them into your overall process design.
  • Integrate medication reconciliation into existing workflow.
  • Make the right thing to do the easiest thing to do within the patterns of normal practice.
  • Develop effective prompts or reminders for consistent behavior if true forcing functions (i.e., required reconciliation step presented to the physician during admission order entry within an electronic medical record) are not possible.
  • Evaluate the potential for workarounds, which includes assessing if new process steps introduce unintended sources of error.
  • Educate patients and their families or caregivers on medication reconciliation and the important role they play in the process.
  • Ensure process design meets all pertinent local laws or regulatory requirements.

B. Building the Foundation for your Medication Reconciliation Process Design

B1. "One Source of Truth"

Process design should center on the concept of a single list to document patient's current medications ("one source of truth"). This list should be shared and utilized by all physicians, nurses, pharmacists and other disciplines caring for the patient - a team approach to medication reconciliation.

  • All disciplines caring for the patient should be working off the same medication list regardless if it is in an electronic or paper-based format.
  • The list should be centrally located and easily visible within the patient's medical record.
  • This list becomes the reference point for ordering decisions and reconciliation, screening medications to be administered during a procedure/episode of care and for determining the patient's medication regimen upon discharge.
  • Each discipline should have the ability to update the home medications as new or more reliable information becomes available.
    • In a paper-based format, old or modified information could be crossed out, new information can be added and each change can be dated/timed/signed.
    • In an electronic system, changes would be date/time stamped and the discipline's name would automatically be captured. If the patient's medication list requires changes at discharge, updated information could remain stored for review and modification for future admissions.

Below is a sample template of "One Source of Truth" for a paper-based system, suitable for customization, to illustrate the collection and verification of a patient's current medication list upon admission/entry to an organization.

Sample Paper-Based "One Source of Truth" (PDF format) - Document/Verify Patient's Current Medications Upon Admission/Entry to the Organization

Below is a screenshot of a Med Profile, an electronic version of "one source of truth" within an electronic medical record.

Med Profile, an Electronic Version of "One Source of Truth" (PPT format)

B2. Defining Roles and Responsibilities for Medication Reconciliation

Now, it's time to determine which discipline(s) should be involved in each step of your medication reconciliation process, including their respective roles and responsibilities. Consider some of the following questions:

  • Which discipline could start building the "one source of truth" upon admission (entry) to the organization?
  • What process steps are needed to perform medication reconciliation on outpatients and inpatients upon admission (entry), intra-hospital transfers (if applicable during a patient's stay) and upon discharge (exit)?
  • What are the required elements for The Joint Commission's National Patient Safety Goal #8 on medication reconciliation?1,2
  • What resources are available within the organization to perform required steps in the process?

During admission and at any point during the episode of care, various disciplines may learn new information regarding a patient's home medications. In addition, physicians, nurses and pharmacists have an active role in reviewing, managing and monitoring a patient's medications. Therefore, consider adopting a team approach for medication reconciliation. Remember, for a team approach to be effective, it is imperative that roles are clearly defined. If there is ambiguity around an individual's role, your process cannot be successful. To help drive this point home, here is a story about four people, Everybody, Somebody, Anybody and Nobody.

"There was an important job to be done and Everybody was asked to do it. Anybody could have done it, but Nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn't do it. It ended up that Everybody blamed Somebody when actually Nobody asked Anybody."3

Therefore, individual roles and responsibilities need to be clearly defined and understood by all disciplines participating on the medication reconciliation team.

To help determine roles and responsibilities, first map out the various admission points in your organization. For procedural areas, consider clinics involved with pre-procedural appointments or areas that register patients and may be able to contribute to your process. Your list may look something like:

  • Direct Admission -> Inpatient Unit (usually from a doctor's office)
  • Procedural Area or Ambulatory Surgery Unit (pre-registered - Early Morning Admissions) -> Inpatient Unit
  • Emergency Department -> Inpatient Unit
  • Triage/Labor and Delivery Unit -> Inpatient Obstetrical Unit
  • External Transfers (patients transferred from an outside hospital) -> Inpatient Unit

Second, determine which discipline(s) within each admission point could initiate building your "one source of truth," and then confirm the list with the patient for "accuracy and completeness."

Below is a sample worksheet to outline process steps for inpatients and outpatients upon admission (entry), discharge (exit) and during intra-facility transfer (inpatients, if applicable) to help you determine which discipline(s) within your organization should be involved in medication reconciliation.

Worksheet for Admission (Entry), Intra-facility Transfer (if applicable) and Discharge (Exit) to help Determine Disciplines' Roles and Responsibilities for Medication Reconciliation (PDF format)

Below is an example illustrating an inpatient process (admission, intra-facility transfer and discharge) and each discipline's roles and responsibilities for medication reconciliation.

Example: Admission, Intra-facility Transfer and Discharge Process Steps and Each Discipline's Roles and Responsibilities for Medication Reconciliation During Hospitalization (PDF format)

B3. Integrating Medication Reconciliation into Your Existing Workflow

Prompts to complete required steps for medication reconciliation are essential. To be effective, prompts or reminders need to occur during the appropriate time within the clinician's workflow. Also, prompts or reminders decrease reliance on memory to perform required steps.

Incorporating prompts or reminders into a clinician's workflow is one example where automation is beneficial. For instance, when a physician enters admission orders for a newly hospitalized patient, the physician can be presented with a medication reconciliation form at that time to document the patient's pre-admission medications and indicate ordering decisions for each medicine (i.e., continue, discontinue, modify, etc.). When the physician signs off on their form, this can trigger a task for the nurse and/or pharmacist to confirm the medication list with the patient for accuracy and completeness and then reconcile this list with current orders to identify unintended discrepancies.

If an organization has a paper-based system, medication reconciliation forms should be kept in the medical record in a highly visible, specified location to serve as a reminder to perform medication reconciliation during the episode of care. Regardless of practice settings, clinicians need effective reminders at the appropriate times within their workflow for consistent behavior if true forcing functions are not possible.

C. Flowcharting your New Design or Redesign for Medication Reconciliation

Once roles and responsibilities are established and you've determined how your new design or redesign of an existing process can be integrated into workflow, a flowchart can be created. The flowchart can illustrate where unnecessary redundancies were eliminated and how each step fits into the existing workflow for each discipline involved in the process. As an example, below are high-level overviews to illustrate our process before and after redesign for admission and discharge.

ADMISSION Medication Reconciliation Process BEFORE and AFTER Redesign (PDF format)

DISCHARGE Medication Reconciliation Process BEFORE and AFTER Redesign (PDF format)

 

Designing the Process Continued

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