Background: Medication reconciliation (MR) is a patient medication verification process performed by providers. Best practices and the intricacies of MR are poorly defined nationally, institutionally, and amongst individual providers. In graduate medical education, the skills of MR are implied and imperative in the Transitions of Care (TOC) Milestones 2.0. Prior institutional studies have indicated only ~9.1% of Internal Medicine (IM) residents at our academic, inner-city hospital performed a MR during patient admission. We aimed to identify current barriers faced and methods utilized by IM residents to complete a MR in order to develop a formal standardized method to implement within the residency program.
Purpose: A survey was sent to IM residents (n=141) inquiring about MR practices. Using resident and hospital leadership feedback, and national guidelines through the Joint Commission and Department of Health, a standardized comprehensive approach to MR was developed. Residents were trained on the new MR method via in-person lectures and provided with an instructional video and physical handouts as visual guides. After 6 months of MR education, residents completed a post-intervention survey. In the post-intervention phase, patient charts (n=25) were audited to determine if the MR was completed utilizing the recommended methods. Based on our needs assessment, the basic pillars included in the methods were: a review of the outside dispense report, creating a clear admission medication list, and a discussion of the most common discharge errors for medication.
Description: Prior to formal MR education, 29% of residents reported that they completed MR for 100% of hospital admissions prior to discharge (n=57). Most residents reported learning how to perform MR from senior residents and noted time consumption as the largest barrier to completion. After the implementation of standardized MR, survey data suggested approximately 66% of residents completed MR for 100% of hospital admissions prior to discharge (n=18). However, when randomly selected charts were checked, only 8% (2/25) of patient charts had adequate MRs completed prior to discharge. None of the MR were completed within 48 hours of admission.
Conclusions: Most IM residents do not complete MR due to time constraints, difficulty navigating the electronic medical record (EMR), and patient factors. Failure to complete a timely MR can lead to various adverse events. We created a resident-led curriculum change by teaching the MR process through multiple modalities: lectures, an instructional video, and handouts. Despite robust education, most MRs were not completed upon patient discharge. This calls for future interventions that involve leveraging the EMR to support clinical decision-making at discharge, role modeling by upper-year residents for interns, and resident accountability. Comprehensive MR skills are a healthcare necessity to deliver safe patient-centered care.