This document outlines a quality improvement project at NMC Royal Hospital in Sharjah to improve medication reconciliation compliance rates. The project team includes physicians, pharmacists, and data analysts. The goals are to reduce errors from omitted or duplicated medications by properly implementing reconciliation. Data on compliance rates is collected and shared monthly. Interventions to address non-compliance include training, reminders, and system changes. The results showed compliance gradually increased from initial rates below 30% to over 50% by the end of the period. The conclusion is that continued monitoring and interventions are needed to further optimize medication safety.

1. NMC Royal Hospital, Sharjah.
Improve Medication reconciliation
compliance rate to optimizing
patient medication safety

2. Team Members
with role
• Dr.Hossameldine–Project Lead
• Mr. Lubab Ponneth– Data collection
and validator
• Mr. Arun Babu–Data Analysis and
Data Interpreter
• Mr.Sathish Kumar–Project Reviewer
and Approver
• Mr.Deepinder singh –Project
Reviewer and Approver
• All Inpatient Pharmacy staff.

3. Aims and Objectives
• To reduce the compliance rate on
medication reconciliation process.
• To implement the safety of medication use
in Hospital by applying the medication
reconciliation process.

4. Expected
outcome
• Increase patient safety related to medications.
• Improvement in existing process which leads to omission or duplication of medication
therapy.

5. GANTT CHART
1/20 2/9 3/1 3/21 4/10 4/30 5/20 6/9 6/29
Define
Measure
Analyse
Improve
Control
Review and Approve
START DATE DURATION
Timeline

6. Brainstorming
Attributes
Initial discussion was conducted to brainstorm on medication reconciliation process not
completely done because of the following reasons.
• Generic form not updated by RMO upon admission time.
• Generic form wrongly updated by RMO.
• Pharmacist not update the generic form before first dose dispensing time.
Other reasons include:
1.Improper communication between doctors and Patient.
2.Patient don’t know about the previous treatment.
3.Patient unconscious and relatives not known about the medication history.
4.During discharge time doctor not update abut the continuity of previously stopped
medications.
5. Doctors are not responding or responsible.
6.Improper communication between RMO and MRP.
7.During discharge time pharmacist fail to reconcile the medication history/Reconciliation
generic form.
Reason
Code
Attributes Action Taken
1 Lack of knowledge of RMO/MRP about the process
All MRP & RMO are educated on importance of
medication reconciliation through training.Memo's
has been issued to all doctors on medication
reconciliation by CMO.Individual docotr training also
provided by pharmacy
2 New staff (Physician/Pharmacist)
Awareness given during the orientation training.
3 Forgot to update on time. Reminder emails circulated to all doctors.
4 System issues. Raise request to make ithe medicaton reconciliation
filed as mandatory.
5 RMO's Busy with other patients. Reminder emails circulated to all doctors.
6 Multiple indents dealing at the same time. Pharmacst is ensuring the admitted patients files
audited for medication reconciliation.
7 Lack of knowledge of Pharmacy staff.
All Inpatient pharmacist are been trained about the
importance of medication reconciliation and perofrm
individaully audit all IP admission files and report
non compliance to concern doctors.
8
Miss communication between staff and Patients & Fail to
take responsibilities and putting to other shift/staff.
Doctors has been educated to perform medication
reconcilaiton at the time of admission and ensure
the patient medication review form.
10
Physical barriers (language, Medication brand, not
labelled medications)
Doctors has been called for the interpreters for
language barrier. Physical medicationbrought by the
patients are verified by pharmacist based on integrity
if not dispensed form pharmacy
11
Patients own medication approval form missing during
the process. Doctrs are edicated on appropriate filling and
sending of patient own medication verification form.

7. Process flow – Medication reconciliation
Patient
admitted in
ward/ICU
Patient came
without
medication/not
have any history
Patient own medication
verification form filled
and signed by doctor
Patient came with
current medication
Medication
approved by
Pharmacy
Review the form during the
dispensing of medications if
any clarification contacted
physician by pharmacist
RMO/MRP document the
medication history in
patients medication review
form
Reconciliation done
by pharmacy team
and save form in the
system
During the discharge time the
Current medication and previous
medications must be compared
and prescribe appropriately
Reconciliation done by
pharmacy team and
finalize the form
Dispense the discharge
medications

8. Standard time format for medication reconciliation
S.N
o
Flow Duration/Timeline
1 Generic form filling On time of admission
2 Patient medication
verification.
1 Hr
3 Reconciliation from
pharmacy
Before dispensing first dose from pharmacy.
4 Discharge medication 30 mins

9. Risks
• Physicians' cooperation.
• Pharmacist cooperation.
• Time management during the communication between physician and pharmacy.
• Delay of dispensing because of miss communication/documentation.
• Delay of treatment.
• Omission/Duplication of medications.
• Hospital reputation.
• Patient satisfaction challenges.
Exclusions
• Emergency cases.
• Outpatient
• Long time care patients

10. Methods
• Data presentation : by table
• Data type : Quantitative
• Method : Observational study and recording
Statistics
• The data was collected and following details were recorded :Total compliance on medication reconciliation
process on daily basis . The same data will be shared with all HOD’s and CMO on regular basis to improve the
compliance from their departments . Quarterly data must be presented in PTC for revision and apply
improvement strategies.

11. Medicines reconciliation Process compliance rate
Parameter 2022 22-Jan 22-Feb 22-Mar 22-Apr 22-May 22-Jun 22-Jul 22-Aug 22-Sep 22-Oct 22-Nov 22-Dec
Medicines Reconciliation N 26 27 35 23 23 18 21 21 42 42 48 48
within 24 hours D 93 83 93 90 90 90 93 92 89 90 89 90
of Admission or Transfer
Compliance
%
27.96% 32.53% 37.63% 25.56% 25.56% 20.00% 22.58% 22.83% 47.19% 46.67% 53.93% 53.33%
Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
27.96%
32.53%
37.63%
25.56% 25.56%
20.00% 22.58% 22.83%
47.19% 46.67%
53.93% 53.33%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
1- JA N 1- F E B 1- MA R 1- A P R 1- MA Y 1- JUN 1- JU L 1- A UG 1 - S E P 1- OC T 1- NOV 1- DE C
MEDICINES RECONCILIATION PROCESS COMPLIANCE RATE
Compliance % Target
Statistics

12. Medicines reconciliation Process compliance rate
Parameter Jan-23 Feb-23 Mar-23 Apl-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23
Medicines Reconciliation within 24 hours
of Admission or Transfer
53 38 83 44 69 75
79 71 71
Total observations 93 82 142 82 82 80 82 76 75
Actual compliance 56.9% 46.3% 58.48% 53.7% 84.6% 93.8% 96.3% 93.6% 94.6%
Target 100% 100% 100% 100% 100% 100% 100% 100% 100%

13. Our Next step-
Interventions for Improvement
Interventions /Action Plan Support Required
Medication reconciliation process make
as mandatory field in Insta
IT support
Continuous monitoring and training to all
doctors.
HR department fix the training as
mandatory for all doctors.
Sending official memo from CMO side
regarding the compliance rate to all
HOD’s
Issue circular from CMO
Pharmacist mention in the EMR as not
updated the Medication reconciliation as
general alert to identify the non
compliance to doctors.
Chief pharmacist circulate internal memo
to pharmacists

14. results

15. conclusion