Abstract: FR-PO960

Prevention of Medication Reconciliation Errors: Results of a QI Study

Session Information

  • Patient Safety
    November 03, 2017 | Location: Hall H, Morial Convention Center
    Abstract Time: 10:00 AM - 10:00 AM

Category: Patient Safety

  • 1501 Patient Safety


  • Singh, Manisha, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Hampton, Temekis D., UAMS, Little Rock, Arkansas, United States
  • O'neal-wright, Sherida R, DCI, Little Rock, Arkansas, United States
  • Sharma, Shree G., Arkana Laboratories, Little Rock, Arkansas, United States
  • Krause, Michelle W., University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States

Medication errors are one of the leading preventable causes of adverse patient outcomes. Accurate reconciliation can greatly decrease this risk. Dialysis patients have increased risk with polypharmacy of up to 5-10 medications/patient. We attempt to enable the patient himself to carry the information for their own care in a quality-improvement project using medication wallets.


Wallet design: Wallet contains contact information, care-buddy details, dialysis unit information, Physician and APN contacts, immunization record, current dialysis prescription with medications, known medical history and allergy information. The wallet has space to keep a driver’s license, credit cards and cash.
Method: Project consisted of 3 phases:
Phase 1: Identify patients for participation.12/15 home dialysis patients consented for study.
Phase 2: Review and compare medications in patient’s record from available admission/discharge lists.
Phase 3: Introduce intervention (Dialysis Wallet) and monitor its effectiveness through a questionnaire-based survey at each clinic visit.


67% of the patients had a medical visit since previous clinic visit. 17% of patients were hospitalized. Their dialysis prescription was unchanged during that hospitalization.100% of patients feel that their dialysis prescription were continued as prescribed.33% of patients felt that, after discharge from medical visit, their medication lists were not updated. They felt that the wallet contributed positively to their care. They reported that other providers appreciated this input at all physician and APN visits. Their immunization records helped expedite care. After the use of this wallet, participants report they would prefer continued use of wallet/hard copy. 67% of patient brought the wallet to clinic visits.


Our results indicate that the medication wallet may be a very effective way to minimize medication errors during transitions and an effective way to enable better patient care. The limitations are failure to update the wallet by some treating teams and patients forgetting to bring the wallet during some treatment visits. We hope that over time, this will get corrected as the importance of this step will be more apparent to providers as well as the patients.