Medication Reconciliation: A Practical Tool to Reduce the Risk of Medication Errors

Peter Pronovost, Brad Weast, Mandalyn Schwarz, Rhonda M. Wyskiel, Donna Prow, Shelley N. Milanovich, Sean Berenholtz, Todd Dorman, Pamela Lipsett

Research output: Contribution to journalArticlepeer-review

246 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)201-205
Number of pages5
JournalJournal of Critical Care
Issue number4
StatePublished - Dec 2003

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine


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