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

This flow diagram highlights the potential gaps and barriers to effective communication about medication orders on admission prior to redesign of a sound medication reconciliation process.

Introductory comments:

• Multiple, independent medication histories obtained from patient and documented throughout the medical record.
• No prompts to cross-reference documentation, which may be conflicting.

Patient admitted to hospital. Information flows from three directions:

1. Nurse obtains medication history and documents in the nursing admission patient assessment form.
2. Consult services and ancillary staff obtain medication histories as part of their initial assessment and document in discipline-specific forms/notes.
3. Physician obtains medication history and documents in admission note ("history and physical"). Changes or updates to history "buried" in progress notes.
   1. Physician orders medications based on med list prior to admission and patient's current clinical status.
      1. No standardized, consistent process for physicians to document and communicate ordering decisions for each home medication. Intended versus unintended discrepancies often unclear.
   2. No standardized, consistent process for medication reconciliation. Increased time spent clarifying discrepancies due to inconsistent physician documentation, often creating double work.
   3. Nurse reviews medication orders prior to administration. Any discrepancies or issues identified are resolved with prescriber.
   4. Pharmacist reviews medication orders prior to verification and dispensing. Any discrepancies or issues identified are resolved with prescriber.
   5. At the final step, nurse administers medications to patient.

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