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CPSI Share                                                  
7/30/2013 6:00 PM

​​Assessing quality processes for MedRec on Admission

The Medication Reconciliation (MedRec) National Call webinar, A Novel Tool to Assess the Quality of Admission MedRec Processes, was presented on June 18, 2013 with 325 lines opened and many more gathered around local computers to learn about quality processes vital to MedRec.

Jennifer Turple, Medication Safety Specialist from the Institute for Safe Medication Practices Canada (ISMP Canada) provided an overview of a new tool to collect patient level data on specific admission quality determinants for MedRec in acute and long term care settings. The tool helps healthcare organizations to qualify and quantify how they are performing the basic tenets of the MedRec process.

The format allows for patient level data collection to be completed using a retrospective chart review following the MedRec process.  Safer Healthcare Now! recommends auditing 10 to 20 charts monthly; however the sample size, strategy, selection, and frequency of the audits are at the discretion of the end-user.

Auditors are designated to review how the medication information was collected, compared, and corrected.  The auditor looks to see if a Best Possible Medication History (BPMH) was created using a systematic process of interviewing the patient or their caregiver; the source(s) of information used to verify all of the patient’s medications (including prescribed and non-prescribed); and if name, dose, route and frequency was collected for all medications.  The auditor then assesses whether all of the medications, as listed in BPMH were for in the admission orders. Finally, the auditor looks for evidence and documents any identified differences that were resolved.

Up to five de-identified patient records can be recorded on pre-printed data sheets, which are then faxed to the Central Measurement Team for assessment.  Using optical marker recognition technology, the results are collated and presented within minutes, using the Patient Safety Metrics system. The aggregated data and reports can be accessed online within one hour.

Alex Titeu, Project Coordinator with the Safer Healthcare Now! Central Measurement Team provided an indepth look at how the data sheets are customized and how data can be segmented to provide information on specific areas in need of process improvement.

Reports generated from the data collection forms include a report by de-identified individual patient (with or without a quality assessment score); an aggregate report by patient population; and an overall score for the organization (both with a quality assessment score). This data can help organizations identify specific aspects of the admission process that are in need of improvement.

To get started with Med Rec in your organization, view the archived webinar or download the PowerPoint presentation, visit and click on Events & Calls/National Calls. 

Canadian MedRec Audit - The Right Thing to Do!

The Canadian Patient Safety Institute and ISMP Canada have partnered to spread the message of safe medication use. During October, a month-long audit will be conducted using the MedRec Quality Assessment tool, to assess the quality of MedRec on admission across Canada.  The results will be tallied and announced on Wednesday, October 30th, during Canadian Patient Safety Week and Canada’s Virtual Forum on Patient Safety and Quality Improvement.  Watch for further details at