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Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital
  1. Vanessa Marvin1,
  2. Shirley Kuo1,
  3. Alan J Poots2,
  4. Tom Woodcock3,
  5. Louella Vaughan3,
  6. Derek Bell4
  1. 1Pharmacy Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  2. 2National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North West London (NWL), Imperial College London, London, UK
  3. 3NIHR CLAHRC NWL, Imperial College London, London, UK
  4. 4Department of Acute Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  1. Correspondence to Dr Vanessa Marvin; vanessa.marvin{at}


Objectives Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge.

Setting An acute 400-bedded teaching hospital in London, UK.

Participants The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months.

Interventions Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives.

Results Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems.

Conclusions New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

  • Medication reconciliation
  • Patient safety
  • hospital pharmacist
  • quality improvement

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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