Authors: (including presenting author): :
SO KF, TSANG LF, CHEUNG TP, LO KP, NG CF, LEUNG LM
Affiliation: :
Nursing Services Division, United Christian Hospital
Keyword 3: :
Medication Reconciliation
Introduction: :
Accurate medication reconciliation is critical to patient safety, yet no single, unified system currently exists to verify a patient's complete drug profile. Information remains fragmented across multiple platforms, including the Electronic Patient Record (ePR), Electronic Health Record (eHR), and paper-based records used by Residential Aged Care Facilities (RACF) and Department of Health (DH) clinics. Consequently, nurses experience difficulty obtaining a comprehensive view of a patient’s medication history. Despite it is the doctor’s responsibility to prescribe the correct medications during admission and discharge, nurses often regard verifying a patient's drug profile as “good practice" rather than a standardized part of the workflow.
Objectives: :
This initiative applied the PDCA (Plan-Do-Check-Act) cycle to transform drug profile checking from a recommended "good practice" into a systematic clinical guide. The primary objective was to establish a robust reference guide that addresses the absence of a centralized system, ensuring comprehensive verification across all fragmented data sources.
Methodology: :
The project followed the PDCA framework: Plan: Identified that fragmented systems (HA, DH, private sectors) lead to incomplete medication histories. Do: Developed the "Streamlined 3-Step Approach" workflow prioritizing Patient/Carer Interviews, followed by ePR reviews and conditional checks for external systems such as eHR and RACF. Check: Presented the reference guide to nursing management and the UCH Medication Monitoring Workgroup for review. Act: Incorporated stakeholders’ feedback and finalized the reference guide as a reference material to standardize the reconciliation process for nurses. The promulgation strategy involved a hospital-wide rollout, including online educational briefings and sharing during various nursing meetings. The recording was uploaded to the intranet, ensuring the guide was easily accessible at the point of care.
Result & Outcome: :
The application of the PDCA cycle successfully operationalized the complex task of navigating disjointed systems. There were four medication incidents involving incorrect checking of patients' drug profiles from Aug 2024 to Aug 2025. Since the initiative’s introduction in September 2025, there have been zero similar incidents. Feedback from frontline colleagues has been positive; clinical teachers reported that the structured flowchart and visual guide significantly improved their clarity on when to access external systems (e.g., DH or private doctors). Governance review during the "Check" phase ensured institutional buy-in and clinical validity. The standardized workflow effectively captures critical data often missing from HA systems—such as "on-hand" medications —thereby elevating the standard of care from a mere suggestion to a safety mandate. Further enhancements to the display platform for one-stop patient drug profiles within HA systems are also recommended to strengthen medication safety in the future.
