Poster - #VH-01604 - Keywords: Transition of care/ Pharmacy-led medication reconciliation /Pharmacy-Assisted medication reconciliation

Transforming Medication Reconciliation: Pharmacy-Assisted Processes in Large Academic Medical Center

Victoria Lubarsky, RPH, MBA, BCACP; Jacqueline Thai, Pharm D; Paige Spencer, BSPS
University Hospitals Cleveland Medical Center

ABSTRACT:
Abstract
Transforming Medication Reconciliation: Pharmacy-Assisted Processes in Large Academic Medical Center
Submission Topic: Safety/Quality
Purpose
UH Cleveland Medical Center, with over 1,000 registered beds, provides comprehensive medical and surgical services. Accurate home medication history collection and admission medication reconciliation are critical during care transitions to prevent harm. Although the medication history team reviews home medication lists for over 85% of daily admitted patients, providers often face challenges with timely and accurate reconciliation. To ensure timely medication reconciliation, the pharmacy team proposed a dual-approach initiative: provider education to ensure reconciliation completion within 24 hours of admission and a pharmacy-assisted process enabling pharmacists to reconcile select medication classes independently or collaborate directly with providers to finalize reconciliation.
Study Design and Data Collection
This initiative aimed to meet the hospital’s quality goal of achieving 90% completion of accurate admission medication reconciliations within 24 hours. A retrospective observational study was conducted over nine months in 2024. Data collected was quantitative, focusing on medication reconciliation completion rates, pharmacist interventions, and provider engagement. Descriptive statistics analyzed trends and measured improvements in reconciliation rates.
Methods
A dual-strategy approach was implemented, incorporating provider education and pharmacy-assisted workflow.
Provider Education
A standardized flow sheet was created to guide providers in medication reconciliation upon admission. Epic patient lists were enhanced with “Medlist Status” and “Admission MedRec Completed?” fields for better visibility. Internal Medicine residents attended educational sessions, and real-time monitoring and education were provided throughout the study.


Pharmacy-Assisted Workflow
A new procedure and real-time dashboard enabled pharmacists to identify patients with incomplete medication reconciliations within 24 hours of admission and intervened by:
• Reconciling select medication classes independently within their procedural scope, including FDA-approved OTC medications, herbal
supplements, duplicate inpatient orders, and long-acting or clinic-administered medications not immediately due.
• Communicating with providers via secure chat to address discrepancies or finalize reconciliation for medications outside their scope.
• Tracking additional medications added post-reconciliation through dashboard monitoring and ensuring proper documentation in I-vents and EMR notes.
The medication history team pre-reviewed medication lists based on MARQUIS Study framework to support reconciliation accuracy.
Results
A quantitative analysis using descriptive statistics was conducted to evaluate changes in medication reconciliation completion rates before and after implementing the initiative.
• Overall reconciliation completion rates increased by 30 percentage points, from 52% to 82% over nine months.
• Pharmacist interventions affected 28% of all admitted patients monthly, with 53% of those cases reconciled independently per policy.
• The pharmacy team's consistent contribution accounted for 15% of the total improvement
• Provider education accounted for an additional 15% of improvements with 13% from pharmacy’s provider outreach and 2% from provider education initiatives and process awareness.

The pharmacy-assisted process was conducted Monday through Friday, up to four hours per day, requiring 0.5 full-time equivalent (FTE) support.
Despite challenges such as variability in provider engagement, resident buy-in, and scope limitations on pharmacist-held medications, the initiative demonstrated that a structured pharmacy-assisted approach combined with provider education led to a significant and measurable improvement in timely and accurate admission medication reconciliation.
Conclusion
This initiative demonstrates the effectiveness of provider education and pharmacy-assisted processes in improving timely and accurate medication reconciliation outcomes and patient safety during care transitions.
Pharmacists played a vital role by educating providers, streamlining the admission medication reconciliation process, and reconciling specific medication classes, enabling them to practice at the top of their license. Consistent provider education, introduced early in resident training, is crucial for this process. Future directions include expanding the pharmacy-assisted process to other care settings to enhance patient safety and care continuity.