Improvements in Medication Reconciliation: Further Steps Towards Engineering a Culture of Safety

Graduation Date


Document Type

Master's Thesis

Document Form


Degree Name

Master of Science



Department or Program Chair

Eira Klich-Heartt, RN, MSN

Thesis Advisor

Eira Klich-Heartt, RN, MSN


This study looks at the effect the transition from a physician-nurse centered medication reconciliation process to one of a pharmacy led reconciliation team with a designated medication reconciliation pharmacy technician would have on compliance with and the accuracy of the medication reconciliation tools and processes at mid-sized community based northern California not for profit hospital. The completion of the study prior to publication became unfeasible when the “go live” date of the pharmacy led team was pushed back to a later date. The results presented are of the initial baseline audit data of the current state of the medication reconciliation tools and processes.

This study shows a snapshot of a medication reconciliation process in transition at a point between the previous entirely handwritten-paper system and the recently instituted electronic health record (EHR), As such, the study indicated that the handwritten reconciliation tool was being used with greater frequency and with greater accuracy than the recently introduced HER medication reconciliation tool with an inconsistent level of transition to the new work process. Examples of the inconsistent levels of transition are the early adoption of the new work process by the pre-registration nurses who consistently and accurately entered patient medication data directly into the EHR, the continued use of the handwritten tools by the ER nurses who were not expected to use the EHR, and inaccurate entry, or lack of update, in the EHR by the floor nurses.

This inconsistent use of duplicate and often contradicting information created an overall discrepancy rate far in excess of the expected discrepancy rate based on other studies. This initial study is of value as it demonstrates the impact that disrupted workflow can have on a key safety process.

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