Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study

Abstract

BackgroundThe first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals.MethodsWe conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression.ResultsA total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions.ConclusionA multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.

Is it time for greater patient involvement to enhance transitional medication safety?

“…In this issue of BMJ Quality & Safety, Schnipper et al report the effects of a refined evidence-based toolkit and mentored implementation of a complex medication reconciliation intervention, 'MARQUIS2', at 18 North American hospitals. 1 This pragmatic quality improvement study used interrupted time series analysis to quantify the effects of implementation on medication discrepancy rates relative to baseline trends. The MARQUIS2 toolkit was developed by refining the earlier MARQUIS1 toolkit, shown to be associated with a reduction in medication discrepancies but with inconsistent improvement among the five study sites.…”

“…Patient ergonomics, a field exploring the science and engineering of patient work, might therefore provide insights into opportunities to modify and nurture patient activation and opportunities for patient involvement in medication reconciliation. 18 The MARQUIS2 patient-level interventions, such as health coaching and patient counselling, 1 were all delivered during the patient's acute hospital stay. The timing of intervention delivery warrants consideration, because a qualitative study of the hospital discharge process suggests that patients are suboptimally involved in discharge preparation and healthcare providers attempt to engage them at times when they are not receptive to this involvement, for example, on the day of discharge when patients may be pre-occupied with making preparations for returning home.…”

“…8 The MARQUIS2 study explored medication reconciliation within the acute hospital work system. 1 Calls have been made for a transitional medication safety focus that extends beyond any individual work system, such as the hospital work system or the primary care work system, because the patient's medication management journey is distributed across time and space and therefore focusing on any one system is insufficient. 8 9 18 19 To fully understand the patient journey and what leads to positive and negative consequences for transitional medication safety, future research could take a systems-based perspective across all relevant and interacting work systems.…”

“…The MARQUIS2 study sought to engage patient and family representatives in intervention development and evaluation by inviting them to contribute to developing discharge education and counselling materials and to be involved in all aspects of the research study. 1 Additionally, community engagement and social marketing to patients as well as clinicians were among the system-level MARQUIS2 stakeholder involvement interventions. These are welcome examples of PPI in medication reconciliation, because there is mounting evidence that PPI enhances the quality, validity and impact of research and service development 23 and yet PPI in medication reconciliation research is relatively rare and has not been described in systematic reviews examining the topic.…”

“…24 Although community engagement and social marketing were recommended MARQUIS2 system-level interventions, only 2 and 3 sites, respectively, of the 18 included study sites actually implemented these components with little detail on the nature of the PPI contributors or contributions to the overall research programme. 1 Information about the facilitators and barriers to the adoption of community engagement and stakeholder involvement at individual study sites would therefore be instructive for those seeking to involve patients and the public in similar healthcare improvements. Articles describing PPI in medication safety research may offer helpful insights into how to conduct and report PPI, such as the types of engagement activities, the stages of the project when engagement might occur, the challenges encountered, the benefits realised and some general tips on supporting collaboration and partnership with patients and the public.…”