This case study first appeared in the report Committed to Safety: Ten Case Studies on Reducing Harm to Patients by Douglas McCarthy and David Blumenthal, M.D.

Organization. OSF HealthCare is an integrated health care network that includes six acute care hospitals in Illinois and Michigan, ranging in size from 42 to 710 beds. It is owned and operated by the Sisters of the Third Order of St. Francis, based in Peoria, Ill.

Lessons learned. Medication reconciliation is essential to preventing adverse drug events. This lesson was reinforced when a glitch in automating the process caused medication reconciliation to fall off for a short time, during which the adverse drug event rate noticeably increased at OSF St. Joseph Medical Center. Given the dispersed nature of medical record-keeping, obtaining accurate information on home medication use can be challenging, said John Whittington, M.D., patient safety officer for OSF HealthCare System. The goal is to obtain the best possible information under the circumstances, recognizing that this results in far better information than what is available when no such effort is taken.

Process improvement projects that cross multiple boundaries, such as those designed to reduce adverse drug events, have the potential to change the organizational safety culture, said Dr. Whittington. Frontline staff must see that management takes patient safety seriously and that everyone will be held accountable for achieving it. Patient safety is a "long-term walk . . . the further you are along the journey, the more you see how far there is to go," Whittington said. Kathy Haig, R.N., patient safety officer at the OSF St. Joseph Medical Center, agreed. "Culture change is not something you do in a year," she said. Three years of concerted effort have reached a tipping point where "true understanding and passion are coming through" from both leadership and frontline staff.

The tools and techniques that Whittington and Haig say have been most valuable to patient safety improvement at OSF hospitals include:

• enhancing root cause analysis (or use of critical event analysis) to encourage deeper thinking about human factors issues and latent causes of safety incidents;
• using failure modes and effects analysis to examine system vulnerabilities and to assess planned changes to help ensure that they decrease rather than increase the risk of harm;
• training to improve teamwork and the use of structured communication skills, such as the Situation-Background-Assessment-Recommendation technique (Case Study 3);
• creating a simulation laboratory to practice teamwork skills, evaluate critical thinking, and learn—through videotaped debriefings—how processes enable errors;
• engaging in collaborative learning among staff at OSF hospitals, which provides ideas and support for improvement;
• making rapid tests of change using the Plan-Do-Study-Act method (Berwick 1998), which minimizes the risks of failure by involving staff in giving feedback at incremental stages of the implementation;
• planning for a measurement strategy, such as the trigger tool to track and understand adverse drug events, and providing monthly reports to management on safety incidents and actions taken to address identified issues.

OSF recently installed electronic health records and automated medication dispensing in the pharmacy. In Haig's experience, technology can be helpful but it is not a cure-all. "People think technology will solve all their problems," but that is not realistic, she said. It requires a lot of up-front work to create a "clean process" to automate. Underlying process failures will show up in "big bright lights" and workarounds will be required to fix them.

Currently, OSF is engaged in efforts to comply with National Quality Foundation-endorsed Safe Practices for Better Healthcare, which are being highlighted through a voluntary hospital survey conducted by the Leapfrog Group, a collaboration among large employers to promote high-impact patient safety practices. OSF expects further regulation and pay-for-performance initiatives to center on these practices. The current voluntary approach to compliance is appealing because it permits hospitals to determine the priority of particular practices and the preferred order for mastering them, Dr. Whittington says.

Dr. Whittington believes that a business case for patient safety can be made when avoidance of adverse events, such as hospital-acquired infections, results in shorter lengths of stay and increased throughput and effective capacity. In other words, efficiency is enhanced when the same facilities serve more people.

Replication and related results. Medication reconciliation is one of six high-impact interventions promoted by the Institute for Healthcare Improvement as part of its 100,000 Lives Campaign (Berwick et al. 2006). The Joint Commission on Accreditation of Health Care Organizations designated medication reconciliation as one of the 2005 patient safety goals required of all accredited hospitals in 2006.

After Luther Midelfort, of the Mayo Health System, in Eau Claire, Wis., implemented a systematic, hospital-wide medication reconciliation process, adverse drug events declined 60 percent from 7.6 per 1,000 doses in 1997 to 3.1 per 1,000 in 2001. A standardized process reduced the amount of time that staff spent on medication reconciliation by half or more, saving an estimated 20 minutes per patient at admission, 30 to 45 minutes at patient transfer from the coronary unit, 35 to 50 minutes at hospital discharge, and 30 minutes per nursing shift (Rozich and Resar 2001). Other related improvements undertaken by the health system have included the following (personal communication with Roger Resar, M.D., 2004):

• developing a standardized protocol for sliding scale insulin, which reduced hypoglycemic events and insulin errors by half (Rozich et al. 2004);
• limiting the number of drug types in a class, such as having one standard narcotic except in case of a patient allergy; and
• improving process reliability by using midlevel practitioners for tasks that do not require a physician's order, such as monitoring and communicating dose changes to the patient.

Implications. Adverse drug events can be substantially reduced through a multifaceted approach that applies human factors principles to reengineer processes through techniques such as the standardization of processes and equipment and the implementation of independent double checks to avert errors.

An effective medication reconciliation process provides more accurate information for safe prescribing and can prevent 15 percent to 20 percent of adverse drug events in a hospital, according to Roger Resar, M.D., a patient safety consultant at Luther Midelfort (Tokarski 2004). If hospitals do not have a systematic process for reconciling medication use at all transition points from admission through discharge, nurses and pharmacists can spend significant time engaged in ad hoc reconciliation as patients move through the hospital, resulting in repeated work and potentially serious errors from incomplete information (Rozich and Resar 2001). Nursing and pharmacy staff have critical roles to play in improving the medication reconciliation process, but "the ultimate reconciliation is the responsibility and duty of the physician, with the appropriate knowledge," Dr. Resar told Medscape Medical News (Tokarski 2004).

Well-designed computerized physician order entry and clinical decision support systems can prevent many serious medication errors with the potential to cause harm (Kaushal et al. 2003). However, these systems cannot eliminate errors caused by incomplete or inaccurate information on home medication use (Bobb et al. 2004). Without a change in the underlying methods of collecting and recording medication history, computerized medical records systems can exhibit the same kinds of inaccurate or incomplete medication information as their paper-based counterparts (Kaboli et al. 2004). Hence, hospitals will continue to need a systematic medication reconciliation process until such time as there are reliable, interoperable electronic health records that faithfully capture a patient's complete medication history.

back to top>

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.