Background: Studies have shown that care transitions represent times of great risk, especially to vulnerable patients; medication reconciliation is a major component of ensuring safe care transitions. Yet, challenges exist to obtaining a best possible home medication list (BPHML) on a provider, patient, and institutional level. Academic hospitals have large pools of in-training providers. Safety net hospitals deliver care to low literacy, limited English-proficiency patients, many of whom have psychosocial barriers to medication adherence. Technically, our institution  lacks an integrated, enterprise-wide electronic health record (EHR) and the capability to effectively document the medication reconciliation process.

Purpose: To improve medication safety during care transitions through an interdisciplinary medication reconciliation process that improves patients’ BPHML at the time of admission, reconciles their inpatient medication list with this BPHML, and develops a discharge medication list within the constraints of our current EHR.

Description: In April 2014, after two years of optimizing the EHR pathway for medication reconciliation, the system was implemented. Four full-time equivalents of multilingual pharmacy technicians were hired to obtain a BPHML which includes standardized processes for patient interviews, calling local pharmacies, nursing homes, families, and county jails. The BPHML is then entered in the EHR and verified by a clinical pharmacist. Technicians based in the emergency room (ER) have access to real-time ER admissions lists. Providers can also electronically request a BPHML when needed.  Medication discrepancies, insurance coverage, high risk medications, and dates of last fill are communicated via an additional note in the EHR. This well-vetted BPHML provides the basis for inpatient prescribing decisions, discharge medication reconciliation, patient medication instructions, and discharge counseling by nurses and providers.

Admissions data collected August 2014-July 2015 show 15235 total admissions with a median age of 51 and over 25% non-English speakers. During this same period, 10139 patient medication reconciliations were performed, representing 85% of the total 11984 admissions through the ER. Of these ER admissions, 34% were on high alert medications and 29% of patients on these high alert medications had medication discrepancies.

Conclusions: A multidisciplinary approach to medicine reconciliation at our urban, academic safety net hospital has been highly successful. Highlights of this approach include consistent collaboration with patients and families, community organizations, pharmacists and pharmacy technicians, clinicians and nurses. Providers have been extremely satisfied with the extensive information documented, as this system has uncovered previously unrecognized medication vulnerabilities. This success was borne of an institutional commitment to improve medication safety at times of care transitions.