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Background
Medication reconciliation is a critical process for ensuring patient safety by preventing medication errors, especially at hospital admission. Despite its importance, compliance with this process in our internal medicine ward was alarmingly low, with an initial baseline of only 4% compliance in January 2019. This prompted the initiation of a quality improvement (QI) project aimed at improving adherence to the medication reconciliation process.
Methods
A team-based approach was implemented, including junior doctors, nurses, pharmacists and the hospital’s information technology team. The plan-do-study-act (PDSA) methodology was used to design, test and implement interventions. Key interventions included educational sessions for junior doctors, integration of pharmacy systems for easy access, daily reminders via a WhatsApp group, and reinforcement of the process by senior residents. Data collection was standardised, tracking patient demographics, reconciliation times and team responsibilities. Compliance was monitored over a 4-month intervention period.
Results
At the start of the intervention, medication reconciliation compliance was at 4%. Initial progress was slow, requiring frequent reminders and educational sessions. However, by the end of the first month, compliance had reached 77%, and by the end of the 4-month period, it improved to 96%, surpassing the target of 90%. This improvement was sustained with a compliance rate above 90% for 6 months following the intervention.
Conclusions
The use of the PDSA methodology significantly improved medication reconciliation compliance, achieving a 96% adherence rate. Engaging healthcare staff through education, clear communication and a team-based approach was key to overcoming barriers and ensuring sustainable improvements. This model can be applied to other QI projects aimed at enhancing patient safety and reducing preventable harm.
Full text
Correspondence to Dr Sher Muhammad Sethi; [email protected]
WHAT IS ALREADY KNOWN ON THIS TOPIC
Medication reconciliation is a critical safety measure in healthcare settings, yet its implementation remains challenging, particularly in resource-limited settings. Previous studies have highlighted barriers to compliance, including workload, inadequate training and unclear responsibilities among healthcare providers. Few studies have investigated systematic quality improvement interventions to enhance medication reconciliation compliance in developing countries.
WHAT THIS STUDY ADDS
This study demonstrates that using the plan-do-study-act (PDSA) cycle in a tertiary care hospital in a developing country significantly improved medication reconciliation compliance from 4% to 96%. The approach highlighted the importance of educating junior doctors, involving multidisciplinary teams and leveraging technology to facilitate the reconciliation process.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study suggests that the PDSA cycle can be an effective framework for improving patient safety initiatives like medication reconciliation in low-resource settings. It also emphasises the value of team-based approaches and continuous education for healthcare professionals. Future research could explore expanding this model to other departments and settings, while policy changes may be needed to standardise medication reconciliation practices across hospitals.
Problem
The Aga Khan University Hospital (AKUH), a 650-bed Joint Commission International-accredited tertiary care teaching hospital in Karachi, Pakistan, recognises medication reconciliation (MR) as a critical patient safety measure. Hospital policy mandates that all admitted patients undergo MR within 24 hours of admission, which includes documenting preadmission medications and reconciling them with the current drug chart. While an electronic MR form was introduced in 2018 to streamline this process, compliance in the Department of Medicine, particularly in the general medicine ward, remained alarmingly low, with a baseline completion rate of only 4%.
Despite formal training included in junior doctors’ induction programmes, the reconciliation process was frequently neglected, placing patients at increased risk of medication errors. This is particularly concerning for patients on multiple chronic medications, where omissions or duplications can lead to adverse drug events, compromised clinical outcomes and loss of patient trust. Although junior doctors were primarily responsible for completing the electronic reconciliation, ward pharmacists and nursing staff also played crucial supporting roles. The lack of a standardised, multidisciplinary approach and inconsistent accountability across teams contributed to ongoing non-compliance and risk to patient safety.
Given the baseline compliance rate of only 4%, the target was set at 90% slightly lower than the ideal standard of 95%, to establish a realistic and achievable benchmark within the project’s time frame, while still representing a substantial improvement in patient safety and adherence to institutional policy.1
Background
Medication errors are a common and significant concern in healthcare settings, particularly during hospital admissions. In 2016, medical errors were estimated to have caused approximately 250 000 deaths in the USA alone.2 A large proportion of these errors, up to 60% occurs during transitions of care, such as transfers from the emergency department to inpatient wards or between different hospital units.3 These errors may occur at various stages of medication management, including prescribing, dispensing and administration.4–8
One of the most effective strategies to reduce prescription and administration errors is the implementation of a comprehensive and timely MR process. As a result, healthcare systems around the world have increasingly adopted standardised MR protocols to improve patient safety. MR involves obtaining an accurate list of a patient’s home medications and comparing it with newly prescribed medications at every transition point in care. According to the WHO, MR is “the formal process in which healthcare professionals partner with patients to ensure a precise and complete medication information transfer at different interfaces of care”.9
Recognising its importance, the Joint Commission established MR as a National Patient Safety Goal, requiring healthcare institutions to maintain accurate records to prevent adverse drug events.10 Electronic MR tools have further facilitated this process by enabling documentation and comparison of medications at key transition points such as admission, transfer and discharge.
Despite its apparent simplicity, implementing a hospital-wide MR programme poses substantial challenges. These include patient uncertainty about their current medications, incomplete or inaccurate documentation during admission, and a lack of standardised workflows. To address these barriers effectively, healthcare providers must clearly understand their roles and responsibilities, particularly in ensuring accurate communication and thorough documentation of home medications.
Measurement
Baseline measurement
Prior to the initiation of the quality improvement project, a baseline audit was conducted in the internal medicine section of The AKUH. Data were extracted from a segmented electronic pharmacy report, which provided key variables including the medical service, time of patient admission, time of MR completion and the responsible physician. Analysis of the electronic records for January 2019 revealed that only 4% of admitted patients had their electronic MR completed within 24 hours of admission.
Given this extremely low compliance, the department prioritised the issue as a formal quality improvement project. The plan-do-study-act (PDSA) model was chosen as the framework for driving systematic change. The initial intervention was implemented across four acute internal medicine teams, comprising interns and residents under the supervision of internal medicine consultants. The project was carried out over a 4-month period from February 2019 to May 2019. This quality improvement project was conducted in accordance with the Standards for QUality Improvement Reporting Excellence reporting guidelines to ensure transparency and rigour in reporting.11
Survey of junior doctors
To better understand the underlying reasons for poor compliance, a written survey was conducted among junior doctors in the internal medicine department. The survey targeted 69 residents and 18 interns (total n=87), of whom 69 responded (54 residents and 15 interns). The proforma included questions about current practice, barriers to regular reconciliation, perceived importance and suggestions for improvement.
Key findings from the survey included:
Only 56.5% (39/69) of respondents reported regularly completing electronic MR.
82.6% (57/69) recognised the importance of MR, especially for preventing harm to patients.
The most frequently cited barrier was heavy workload, particularly during on-call days.
Other contributing factors included limited access to computer terminals, lack of awareness of the process (especially among newly inducted interns), and unclear accountability within teams.
Notably, 46.4% (32/69) suggested that involving another member of the primary team to double-check entries could help improve compliance.
Root cause analysis
Following the survey, the multidisciplinary project team conducted a root cause analysis to synthesise and prioritise the barriers contributing to low compliance. These were illustrated in a cause-and-effect diagram (figure 1) and supported by a 1-week observational survey (figure 2), which reinforced that the primary challenge was the workload of junior doctors, especially during high-demand periods such as night calls.
Additional factors included:
Insufficient training on the electronic reconciliation process.
Inadequate awareness of the hospital’s MR policy among junior staff.
Poor recall of home medications by patients or family members.
Limited perceived accountability for completing reconciliation.
System-related or software-related issues were not identified as significant contributors.
These findings were consistent with previous literature, which also highlights time constraints, unclear roles and lack of standardised processes as key barriers to successful implementation of MR programmes.12–16
Design
This quality improvement initiative was developed using a multidisciplinary, team-based approach to address poor compliance with electronic MR within the internal medicine department of the AKUH. The core team included an internal medicine consultant, the department’s chief resident, a lead ward nurse, a clinical pharmacist and representatives from the hospital’s information technology (IT) department. The collaborative nature of the team ensured inclusion of diverse insights and fostered shared ownership of the intervention.
Recognising the complexity of isMR is often noted to be resource-intensive and challenging to standardise across transitions of care.17 We designed a workflow that explicitly involved junior doctors (residents and interns), nursing staff and pharmacists. Consultant physicians of internal medicine were also informed of the project and invited to support the implementation. Patients and the public were not directly involved in the design, conduct or dissemination of this quality improvement initiative.
To systematically track progress and identify gaps, a standardised data collection form was developed. It captured key metrics including:
Patient demographics and bed number.
Admission date and arrival time in the ward.
Medication entry time into the electronic system.
Responsible team and supervising consultant.
Delays in reconciliation (beyond 24 hours).
Team member (intern or resident) completing the task.
The standardised data collection form was implemented as an electronic Excel-based tool. It was completed daily by a designated nurse specialist using data extracted directly from the hospital information system, ensuring real-time monitoring and immediate feedback.
Strategy
The intervention was structured around iterative PDSA cycles and implemented over 4 months (February–May 2019). The following strategies were introduced to address the root causes of non-compliance:
Education and awareness
Conducted multiple educational sessions (formal and informal) for interns and residents on the importance and process of electronic MR.
Developed and disseminated instructional materials outlining step-by-step guidance for completing the electronic reconciliation form.
Encouraged admitting teams to perform reconciliation during initial patient clerking, with reinforcement on day 2 by senior residents.
Role clarification and accountability
Designated the primary admitting team as responsible for completing MR within 24 hours.
Assigned senior residents the role of verifying and double-checking the process the following day.
Requested internal medicine consultants to regularly monitor and follow-up with their teams through daily email summaries.
Communication and feedback
Created a WhatsApp group led by the specialist nurse for real-time compliance updates across the four acute medicine teams.
Teams were notified daily about their reconciliation status via WhatsApp and phone calls, based on data extracted from the pharmacy system.
System and workflow improvements
Collaborated with the IT department to enhance accessibility of the pharmacy system on junior doctors’ personal laptops and mobile devices within hospital premises.
All existing computer stations were checked and repaired if needed to ensure optimal system performance.
Requested a modification in the pharmacy software so that electronic MR became a prerequisite before allowing admission medications to be entered.
Shared responsibility and workflow optimisation
Introduced a checklist for commonly prescribed medications to help junior doctors recall typical home medications.
Encouraged nursing staff and family members to assist in obtaining accurate medication histories.
Ensured equitable distribution of reconciliation tasks across all junior doctors, with regular counter-checks to maintain accountability.
The strategy emphasised making the process simpler, more efficient and accessible—thereby reducing the burden on junior doctors while improving compliance. A detailed process flow chart summarising the revised workflow was created (online supplemental figure 1).
Results
At the outset of the project in January 2019, baseline compliance with the electronic MR process in the internal medicine ward was done on only 26 patients out of 642 (4%). Initial implementation faced several challenges, including resistance from junior doctors, logistical constraints from pharmacy and IT systems and limited awareness among clinical staff.
Despite a slow start during the first 2 weeks, targeted interventions such as frequent reminders from the nurse lead and multiple educational sessions for interns and residents began to show results. By the end of the first month, compliance improved significantly to approximately 77% (510/661) of patients, marking a substantial jump from baseline.
Progress continued steadily through the course of the intervention. By the end of the 4-month implementation period (May 2019), the project had surpassed its original goal of 90%, achieving a final compliance rate of 96% (742 out of 772 patients) for electronic MR (figure 3). This marked a 24-fold improvement from baseline and exceeded the predefined target, reflecting strong engagement across all stakeholders.
In addition to improved compliance rates, there was a noticeable enhancement in the accuracy and completeness of reconciled medications, aligned more closely with patients’ preadmission medication records. This reinforced the importance of involving multidisciplinary teams and using a structured PDSA cycle to drive sustainable change.
To assess long-term sustainability, follow-up audits were conducted over the subsequent 6 months after the intervention. These revealed that compliance remained consistently above 90%, although full (100%) compliance was not achieved across all teams at all times. Nonetheless, the maintenance of high compliance post-intervention indicated successful integration of the new workflow into routine clinical practice.
Lessons and limitations
Improving the MR process had a direct impact on enhancing patient safety by reducing the risk of unintentional harm due to missed home medications. Using the PDSA methodology, our team successfully implemented practical, evidence-informed interventions that elevated compliance from 4% to 96% over the 4-month study period.
Key to this success was our emphasis on basic, time-tested strategies such as data collection, analysis and real-time feedback. Early group discussions with junior doctors and a structured survey allowed us to deeply explore the root causes of non-compliance. Using those insights, we developed and refined our interventions, sharing performance data and progress updates regularly with all stakeholders. This transparency helped foster a culture of ownership and accountability.
One of the most impactful elements was targeted education and awareness sessions. Although junior doctors were initially briefed on the MR process during their induction, our data revealed significant knowledge gaps. Tailored educational efforts helped bridge these gaps, and highlighting the patient safety implications of proper reconciliation further motivated junior doctors to take ownership of the process—even in the face of heavy workloads.
A team-based approach proved essential to the success of the intervention. We involved nurses, pharmacists, consultants and the IT department from the outset. Communication was kept friendly and non-hierarchical, which encouraged collaboration. Tools like WhatsApp groups, phone calls and emails enabled real-time updates and accountability without adding to the junior doctors’ burden. This informal, cooperative model transformed traditional dynamics, enhancing interprofessional relationships and promoting a shared sense of responsibility.
Despite the notable success, our approach had several limitations:
High initial reliance on reminders: At the start of the project, nearly 80% of admissions required active follow-up by the specialist nurse or pharmacy team to ensure reconciliation was completed. While this decreased over time as education and habits improved, the model initially depended heavily on human reminders and real-time follow-up.
Limited scope: The intervention was confined to the internal medicine department. Junior doctors from surgical or specialty wards, which may have different workflows and priorities, were not included. Therefore, the generalisability of these findings to other departments remains untested.
Technology-dependent communication: Our strategy leaned heavily on digital communication tools like WhatsApp and email. While effective in our context, reliance on such tools may not be feasible in settings with limited access to smartphones or stable internet connectivity.
Sustainability concerns: Although high compliance was maintained for 6 months postintervention, long-term sustainability will depend on ongoing education, reinforcement and integration of the reconciliation process into standard practice—without continuous external reminders.
Limited assessment of clinical impact: The study assessed compliance with the completion of MR but did not directly evaluate the accuracy of the reconciled medication lists or the impact on medication errors and adverse drug events. Future work should aim to address these important clinical outcomes to better understand the full benefit of such interventions.
Future efforts should aim to scale and adapt this intervention across the hospital, including departments with varying workflows and patient needs, to evaluate broader applicability and sustainability and understanding all clinical outcomes from such interventions.
Recent advancements in our institution in medicine reconciliation
A recent study published by the Quality and Safety Department of our hospital reported a significant improvement in physician-led MR, with completion rates increasing from 32.7% in 2018 to 69.4% in 2021.18 Additionally, our electronic health record system has since been upgraded to mandate MR at the point of patient admission requiring completion by the physician before any further medication orders can be entered.
Most recently, in the first half of 2025, an internal departmental audit demonstrated further progress, with compliance rates reaching 80%–85% in the private ward and 70%–75% in the general ward. These ongoing audits reflect sustained institutional commitment and evolving system-level support for improving medication safety.
Conclusions
The application of the PDSA cycle proved to be an effective framework for improving MR compliance at our institution. Through targeted interventions and continuous monitoring, we were able to achieve a remarkable increase in compliance, from just 4% to 96%, significantly enhancing patient safety and reducing the risk of preventable harm due to missed medications.
This methodology not only delivered immediate results in the internal medicine department but also provides a scalable model that can be applied to other quality improvement initiatives within healthcare settings. By using data-driven strategies, regular feedback and collaboration across multidisciplinary teams, similar approaches can be implemented to tackle various quality indicators and improve overall patient safety.
Furthermore, the success of this project shows the importance of engaging healthcare staff at all levels. Involving team members in the change process, addressing their concerns and fostering a culture of collaboration played a crucial role in overcoming initial resistance and facilitating the development of long-term, sustainable solutions.
Contributors ASA and AZ were primarily responsible for the design, execution and initial drafting of the manuscript. SMS provided critical review, contributed to the revisions and managed the submission and correspondence process. All authors contributed meaningfully to the development of the final manuscript and approved it for submission. ASA is the guarantor of the study and takes full responsibility for the integrity of the work and the accuracy of the data analysis. In the preparation of this manuscript, ChatGPT was used to assist in drafting, structuring and refining the text. However, the content and interpretation of the research findings, along with the methodology, conclusions and overall study design, were independently developed by the authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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