Background: Up to 67% of patients have at least one medication error on admission to the hospital with over a quarter of hospital prescribing errors attributed to incomplete medication histories at admission. Key aspects of successful interventions to date include intensive pharmacy staff involvement. However, pharmacists are in short supply in many hospitals.
Methods: A quality improvement project to improve completion and accuracy of admission medication reconciliation was undertaken at the Cleveland Clinic Main Campus starting in October 2016 on the general medicine teaching services. A multidisciplinary team huddle including a pharmacist embedded on the physician team, senior medical resident and medical attending was arranged to discuss admission medication reconciliation status at the start of rounds daily (Monday-Friday). The huddle focused on patients with an incomplete admission medication reconciliation and those that flag as high risk (for high risk medications and/or an elevated modified LACE score [“LACE” = length of stay, acuity of admission, Charlson comorbidity index, emergency department use]). A team discussion and plan was formulated to complete medication reconciliations when needed and further investigate the medication history for high risk patients. The intervention was implemented on one medical team and then scaled to two and then three medical teams. A sampling of patient lists was completed during the morning hours daily to determine the number of patients with complete and incomplete admission medication reconciliations in the electronic medical record.
Results: The huddle took on average 4minutes and was completed 86% of the days studied. The % of patients with a complete admission medication reconciliation was 96% on the teams with a multidisciplinary huddle compared to 81% on the teams without an embedded pharmacist and without a huddle. The % of patients with a pharmacist review of the medication history increased from 11% before the huddle on teams with an embedded pharmacist to 65% on these teams after the huddle was implemented.
Conclusions: A multidisciplinary team huddle involving a pharmacist embedded on a medical team helps to improve admission medication reconciliation completion and helps to increase pharmacist engagement in the admission medication history review process. This in turn has the potential to improve patient safety and reduce adverse drug events as the literature considers the best possible medication history by a pharmacist as superior in accuracy.