Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation

Following implementation of the medication reconciliation process it is essential to start auditing the process. Auditing will allow you to assess and evaluate the success and identify opportunities for improvement.

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.

Selecting and Reporting Results Metrics From Your Audit

The section below will help you develop your data collection strategy for audits.

Medication Reconciliation Audit Form

Unit:___________________ Manager:_____________________ Date:___________________________

Data Collector's Name:_ ________________________________________________________________

Introduction:

• The data is to be collected and reported on a __________ basis.
• During each _________, a total of _________ charts should be selected for record review.
• Findings are to be tracked through your own quality process.
• Provide copies of the completed audit form to _______________________________________

Instructions:

Medication reconciliation is the process of comparing medications the patient has been taking prior to admission/entry to the hospital to the medications the organization is about to provide to identify any unintended discrepancies. If a patient will be provided/given any medications while under our care or prescribed any new drugs to take after their stay, medication reconciliation is required.

1. Confirm a medication list was collected from the patient upon arrival to (list must include medication name, dose, route, and frequency).
2. The list must then be available in the patient's chart for the caregiver to review prior to initiating care.
3. Identify that the complete and updated list of medications was then provided to the patient at discharge and discussed within the context of discharge instructions ("resume home meds" is not acceptable).

If you observe someone NOT doing the right thing, ask the following questions:

1. Is this a supply/logistic issue (can't find forms, pens, etc.)? ______________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

2. Is this a performance/knowledge/skill issue? ________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

3. Is this a human factors (distraction, noise, fatigue) issue?________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

4. Other barriers to compliance? ___________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Goal: 100% Compliance

Numerator:

• Number of medication lists collected and completed on outpatients requiring medication reconciliation.
• Number of medication lists that were provided back to outpatients in the context of discharge instructions.

Denominator: Number of outpatients requiring medication reconciliation.

The chart below represents an example of an audit reporting chart that could be used to communicate audit reporting results on any given day. The number of charts reviewed will vary depending on the size of your organization.

Audit Reporting Chart