AUTHOR BIOGRAPHY
Kai Xu, MD, Good Shepherd Penn Partners Rehabilitation. Penn Medicine Rehabilitation Unit, Hospital of the University of Pennsylvania Perelman School of Medicine at the University of Pennsylvania
Kai Xu is a medicine consultant for the inpatient rehabilitation program at the Hospital of the University of Pennsylvania. He is an associate clinical professor of Medicine at the Perelman School of Medicine and a core faculty in the Clinical Informatics Fellowship. Dr. Xu specializes in the implementation and optimization of electronic health records (EHR), as well as the evaluation and integration of emerging technologies to transform clinical care and enhance patient experience. He has played a pivotal role in developing institutional guidelines for EHR usage, optimizing clinician workflow, and standardizing clinical care practices. His expertise extends to performance improvement methodologies, with a focus on advancing quality of care and patient safety.
Nina Renzi, BSN, RN, Good Shepherd Penn Partners Rehabilitation. Penn Medicine Rehabilitation Unit, Hospital of the University of Pennsylvania
Nina Renzi (nina.renzi@pennmedicine.upenn.edu) is a nurse with over 30 years of experience in various specialties. She is the director of Patient Safety, Risk, and Regulatory at Good Shepherd Penn Partners (GSPP) Rehabilitation and serves as the patient safety officer. Renzi earned her nursing diploma in 1993 and a Bachelor of Science in nursing in 2013. She is currently pursuing a juris master’s in health law. Renzi is certified in patient safety and healthcare risk management. At GSPP Rehabilitation, Renzi focuses on enhancing patient safety by identifying and analyzing adverse events. She implements measures to prevent future incidents, ensuring continuous improvement in patient care standards.
*Corresponding author
Lauren Ragusa, MSN, Penn Medicine Rehabilitation Unit, Hospital of the University of Pennsylvania
Lauren Ragusa is a skilled and compassionate nurse practitioner with a diverse background in patient care. She began her healthcare journey by earning her undergraduate degree in nursing at Loyola University Chicago, followed by her Master of Science in Nursing degree with a focus on family medicine. With three years of experience as a registered nurse in orthopedics, trauma, and neurology, Ragusa developed a strong foundation in acute care and specialized medical fields. Building on this knowledge, she transitioned to the role of nurse practitioner and has now spent three years practicing in physical medicine and rehabilitation. Ragusa is deeply committed to helping patients recover and regain their quality of life through holistic, evidence-based approaches. Her expertise in both acute and rehabilitative care allows her to provide comprehensive, personalized treatment plans to address a wide range of physical conditions.
ABSTRACT
Background
Medication errors are common, especially during care transitions, and associated with adverse patient outcomes. Effective medication reconciliation is essential to prevent errors. Multiple medication discrepancies were documented on admission to the post-acute care facilities within a large academic medical center. These patients missed at least one dose of an important medication that was on their medication list from the discharging hospital. It was discovered that providers were inconsistently using the admission medication reconciliation (AdmMedRec) tool within the electronic health record.
Methods
Using failure mode and effects analysis, key contributing failures were identified in the existing AdmMedRec process. An interdisciplinary team was assembled to design and implement interventions using iterative Plan-Do-Study-Act cycles to improve AdmMedRec completion rates and reduce medication errors. We developed a standardized workflow, an educational curriculum, and a feedback mechanism to achieve these goals.
Results
AdmMedRec completion rate significantly improved from 13% to 87% in the inpatient rehabilitation facility and from 51% to 82% in the long-term acute care hospital in the four months after project implementation.
Conclusions
Our interventions significantly improved AdmMedRec compliance and reduced medication errors upon admission.
Plain Language Summary
When a patient is transferred from one hospital or facility to another, one important step in the hand-off process is admission medication reconciliation (AdmMedRec), during which the patient’s current medications are recorded and a healthcare provider reviews the list to determine whether to continue, hold, substitute, or discontinue each medication. Medication errors may occur during AdmMedRec, resulting in patients not receiving one or more doses of an important medication. There are many challenges to AdmMedRec, including low compliance rates and a lack of a defined process or formal training.
When a large academic medical center noted multiple errors related to AdmMedRec, an interdisciplinary team investigated the causes and designed and implemented interventions, which were refined in rapid, iterative “Plan-Do-Study-Act” cycles. Through this improvement initiative, they introduced a standardized AdmMedRec workflow, developed education (including one-on-one training and a tip sheet), introduced an AdmMedRec dashboard in their electronic health record, monitored medication reconciliation status and proactively reached out to providers, and collected feedback. These comprehensive and collaborative efforts resulted in significant increases in AdmMedRec completion rates in the facilities in which these interventions were rolled out—as well as an anticipated decrease in the number of medication errors.
