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

Medication reconciliation is a complex process that impacts all patients as they move through all health care settings. It is a comparison of the patient's current medication regimen against the physician's admission, transfer, and/or discharge orders to identify discrepancies. Any discrepancies noted are discussed with the prescriber, and the order is modified, if necessary. (A complete definition of medication reconciliation is available in the Appendix.)

Although this toolkit is based on processes developed in acute-care settings, the core processes, tools, and resources can be adapted for use in non-acute facilities.

Medication reconciliation is a process to decrease medication errors and patient harm in the following ways:

• Obtaining, verifying, and documenting the patient's current prescription and over-the-counter medications—including vitamins, supplements, eye drops, creams, ointments, and herbals—when he or she is admitted to the hospital or is seen in an outpatient setting.
• Considering the patient's pre-admission/home medication list when ordering medicines during a hospital encounter and continuing home medications as appropriate, and comparing the patient's pre-admission/home medication list to ordered medicines and treatment plans to identify unintended discrepancies (i.e., those not explained by the patient's clinical condition or formulary status).
• Verifying the patient's home medication list and discussing unintended discrepancies with the physician for resolution.
• Providing an updated medication list and communicating the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter.

The effectiveness of a sound medication reconciliation process within and among care settings is an important component of patient safety goals. While many health care providers already have medication reconciliation processes in place, this toolkit will facilitate a review and improvement of current practices to strengthen the process with the result of improved patient safety.

This toolkit is based on the Medications at Transitions and Clinical Handoffs (MATCH) Web site developed through the support of the Agency for Healthcare Research and Quality and collaboration between Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine in Chicago, Illinois, and The Joint Commission. It is available at: http://www.nmh.org (search for "toolkit"). In addition to elements from the MATCH Web site, this toolkit also incorporates the experiences and lessons learned of facilities that have implemented MATCH and facilities that received technical assistance on MATCH through the AHRQ Quality Improvement Organization (QIO) Learning Network.

While your facility may already have a medication reconciliation process in place, this toolkit will help you evaluate the effectiveness of the existing process, as well as identify and respond to any gaps. It promotes a successful approach to medication management and reconciliation that emphasizes standardization of the process for doctors, nurses, and pharmacists within the facility to document and confirm a patient's home medication list upon admission. It also emphasizes the need to clearly define roles and responsibilities of clinical staff. Standardizing the process for collecting home medication lists, as well as the location and means of documenting this information, ensures that the most accurate, complete medication history is documented for each patient; all the inpatient and home medications are reconciled; and the information is accessible to the entire health team.

How to Use This Toolkit

This toolkit provides a step-by-step guide to improving the medication reconciliation process. Users are encouraged to follow the steps in the order presented. Each step builds upon the next to present a systematic methodology for critically reviewing and improving the medication reconciliation processes.

This toolkit is divided into seven components to assist with improvement:

1. Building the Project Foundation: Gaining Leadership Support within the Organization.
2. Building the Project Foundation: Project Teams and Scope.
3. Developing Change: Designing the Medication Reconciliation Process.
4. Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process.
5. Education and Training.
6. Assessment and Process Evaluation.
7. High Risk Situations for Medication Reconciliation.

The Appendix also functions as a Work Plan to implement medication reconciliation in your facility according to the MATCH principles. The Work Plan is available as a standalone file so you can print multiple copies for use with leadership, design, and implementation teams.