Background Hillerød Hospital is a mid size teaching hospital in the capitol region of Denmark with 49.105 discharges in 2010. The hospital has one emergency room/admission unit and has 19 wards where medication reconciliation (MR) is performed. Before this effort, MR was not routinely performed, putting patients at risk of receiving wrong or inadequately dosed medications during admissions and after discharges.

Purpose The purpose of the task is to improve medication reconciliation (MR) at admission and discharge.

Materials and methods

• ▶ A pharmacist together with a physician or nurse audited 10 files monthly for up to 10 clinical units. Variables (yes/no) were:

• ▶ MR at admission

• ▶ List of medications in admission note

• ▶ All medications registered in the electronic medication system

• ▶ MR at discharge

• ▶ MR in discharge summary

• ▶ Identical list in electronic medication system and discharge summary

• ▶ Data were registered in a spreadsheets

• ▶ The authors calculated the percentage of patients with MR at admission and discharge for each unit. Results were aggregated for the whole the hospital. All data were plotted as run charts for MR at admission and at discharge for each variable.

Results MR at admission increased from 60% to up to 90%, on some wards to 100% during 2008–11. MR at discharge increased from 20% to 80%. The authors find large variations by ward of MR at discharge (5 to 100%).

Conclusions It is possible to implement medication reconciliation at admission and discharge because of the positive forces for change in our organisation. Most important is a committed change agent (Nina Grüner), interdisciplinary teamwork and the availability of high quality data and support from leaders in the later phase of the project. Well even higher reliability of medication reconciliation requires deeper integration of process routines in the clinical units through small scale testing.