Cited by 371Patient Safety and Medication ErrorsPharmaceutical Practices and Patient OutcomesPharmacovigilance and Adverse Drug Reactions

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Medication reconciliation: a practical tool to reduce the risk of medication errors

Pronovost, Peter, Weast, Brad, Schwarz, Mandalyn, Wyskiel, Rhonda M, Prow, Donna, Milanovich, Shelley N, Berenholtz, Sean, Dorman, Todd, Lipsett, Pamela·2003·Journal of Critical Care

DOI 10.1016/j.jcrc.2003.10.001

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Abstract

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

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Medication Reconciliation: Developing and Implementing a Program
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Self-citation
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Background
Evaluation of Multimedia Medication Reconciliation Software: A Randomized Controlled, Single-Blind Trial to Measure Diagnostic Accuracy for Discrepancy Detection
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From Hospital to Home Healthcare
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“The instrument was developed specifically for this study because other instruments reported in the literature were oriented to inpatient use (Ketchum et al., 2005; Pronovost et al., 2003; Rodehaver & Fearing, 2005; Rogers et al., 2006; Rozich et al., 2004) and have limited utility for home healthcare application.”
Method
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“This process is based on the safety principle of independent redundancies—having independent checks, generally by different providers, for key steps in the process.(14)”
Background
Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial
Boockvar, K. S., Koufacos, N. S., May, J., Schwartzkopf, A. L., Guerrero, V. M., Judon, K. M., Schubert, C. C., Franzosa, E. C., & Dixon, B. E. (2022) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07397-5 · Cited by 12
Simulation Modeling of a Check‐in and Medication Reconciliation Ambulatory Clinic Kiosk
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Background
Impact of continuous pharmaceutical care led by clinical pharmacists during transitions of care on medication adherence and clinical outcomes for patients with coronary heart disease: a prospective cohort study
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Background
Positive Medication Changes Resulting from Comprehensive and Noncomprehensive Medication Reviews in a Medicare Part D Population
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Background
Medication Reconciliation: Work Domain Ontology, prototype development, and a predictive model.
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“…debate, we do understand a great deal more about medication errors, hand-off related errors, hospital-acquired infections, and wrong-side procedures than we did 10 years ago (Campion, 2003; Gandhi, 2005; Heimann, 2005; Jagsi et al., 2005; Pronovost et al., 2003; Weick, Sutcliffe, & Obstfeld, 2005).”
Background
Medication review software to improve the accuracy of outpatient medication histories: protocol for a randomized controlled trial
Lesselroth, B., Dorr, D. A., Adams, K. A., Church, V., Adams, S., Mazur, D. J., Russ, Y., Felder, R. S., & Douglas, D. (2011) · Human Factors and Ergonomics in Manufacturing & Service Industries · doi:10.1002/hfm.20287 · Cited by 10
“…Factors and Ergonomics in Manufacturing & Service Industries 22 (1) 72–86 (2012) c© 2011 Wiley Periodicals, Inc. and poor interprovider communication (Pronovost et al., 2003; Boockvar, Carlson LaCorte, Giambanco, Fridman, & Siu, 2006; Varkey & Resar, 2006; Vira et al., 2006; Orrico, 2008; Pippins…”

Authors: Pronovost, P., Weast, B., Schwarz, M., Wyskiel, R. M., Prow, D., Milanovich, S. N., Berenholtz, S., Dorman, T., & Lipsett, P.
Affiliations: Johns Hopkins University (US)
Corresponding author: Pronovost, Peter
ORCID: Pronovost, Peter
Dorman, Todd
Lipsett, Pamela
Venue: Journal of Critical Care
Publisher: Elsevier BV
Published: 2003-12
Volume: 18
Issue: 4
Pages: 201-205
ISSN: 0883-9441 (ISSN-L)
DOI: 10.1016/j.jcrc.2003.10.001
OpenAlex: W2137815358
Cited by: 371
References: 20
Citations by year: 2026: 4 · 2025: 7 · 2024: 11 · 2023: 11 · 2022: 12 · 2021: 12 · 2020: 12 · 2019: 13 · 2018: 18 · 2017: 23 · 2016: 15 · 2015: 27 · 2014: 17 · 2013: 20 · 2012: 20
FWCI: 17.34
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: Journal of Critical Care (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Pharmacovigilance and Adverse Drug Reactions
Keywords: medication reconciliation, medication errors, adverse drug reactions, intensive care unit discharge, surgical intensive care unit, electronic health records, medication orders, patient safety
MeSH terms: Continuity of Patient Care, Hospitals, University, Humans, Intensive Care Units, Medication Errors, Medication Systems, Hospital, Patient Care Team, Patient Transfer, Quality Assurance, Health Care

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Medication reconciliation: a practical tool to reduce the risk of medication errors

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