Background: High-quality, accurate, and timely prior-to-admission (PTA) medication reconciliation, the process of establishing a complete PTA medication list, is an essential component of safe inpatient care. At many institutions, hospital medicine patients are often admitted by swing or night admitters, with care assumed by direct-care hospitalists the following day. Though prior qualitative studies have examined discrepancies in medication reconciliation practices across interprofessional roles (e.g. physician vs nurse) and practice settings (e.g. hospitalist vs primary care), variation among different hospitalist roles (e.g. admitting vs direct-care physician) is less well-characterized [1-3]. Understanding role-based sources of variation in these multi-handoff settings is critical for improving the quality and reliability of medication reconciliation.
Methods: We conducted three focus groups exploring hospitalists’ medication reconciliation workflows across direct-care, swing-admitting, and night-admitting roles. Participants were recruited via email and announcements at a weekly division meeting in a large urban academic hospital medicine division. We used a standardized question guide developed by investigators based prior literature and institutional priorities, with questions focused on provider workflows, verification practices, and communication around medication reconciliation. Focus group notes were analyzed using inductive content analysis to identify emerging themes.
Results: Participants self-identified as direct care hospitalists (N=9), swing admitters (N=4), or nocturnists (N=7). Thematic analysis revealed that lack of process standardization contributes to duplicate work, high cognitive load, and inconsistent medication reconciliation outcomes. Three key areas of variation in hospitalists’ practice patterns emerged (Table 1): (1) Role-based variation: As medication reconciliation responsibilities are distributed across multiple hospitalist roles without clearly defined expectations for each role, work is often duplicated or missed. (2) Ambiguity in expectations and best practices: Reconciliation is often complex for hospital medicine patients, who commonly take many PTA medications and may be unable to accurately report use, necessitating reliance on alternative information sources and individual hospitalist judgment for certain categories (e.g. as-needed medications) and resulting in inconsistent practices and outcomes. (3) Documentation practices: Clinicians use variable methods to document medication status (e.g. free-text notes vs. direct medication list edits) and share information (e.g. EMR-based tools vs. patient notes), creating ambiguity for physicians assuming care during handoffs.
Conclusions: Medication reconciliation practices vary by hospitalist role, verification approach, medication list management, and documentation. Findings can directly inform the design of role-based expectations and standard workflows to improve quality, accuracy, and reliability of medication reconciliation in multi-handoff care.
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