Case study showing significant improvement in medicine reconciliation

19 Aug 2013 | Medication Safety

An American case study from the Agency for Healthcare Research and Quality (click here to view) illustrates a program from Contra Costa Health Services put in place using the IHI Model for Improvement, and has resulted in significant improvements in the medication reconciliation process.

In June 2005, the Contra Costa Health Services team met for the first time and has been meeting weekly ever since. They have nearly reached their stated program goals, which are to eliminate un-reconciled medications at transition points (admission, transfer, discharge) and to achieve 100 percent compliance with the paper form usage.

Their tips for sustaining this medication safety intervention include:

  • Use neutral leadership: Use a neutral team leader who is not wedded to one approach and who can facilitate conversations between multidisciplinary team members at weekly meetings.
  • Hold efficient meetings: Make weekly team meetings short but productive to keep momentum.
  • Consider new improvements: Be open to continual refinement of the process as it is used by the frontline staff. Look at the non–value-added and duplicated work that can be eliminated eg, multiple medication history taking by different health professionals.
  • Conduct on-going measurement: Continue to measure and report outcomes, as clinicians are motivated by seeing positive results.
  • Accept gradual improvement: Do not be discouraged if outcomes are not "perfect" initially or even over time. Project teams may face barriers along the way that must be overcome. The key is to gradually become better and to use this improvement as a motivation to keep going.

The Commission would like to eproduce a series of cases studies showing what organisations in New Zealand are doing to spread and maintain the medicine reconciliation process. If you would like to be involved, please contact Nirasha Parsotam (

Last updated 19/08/2013