Improving the Use of Medicines Reconciliation Information in Inpatient Prescribing on an Elderly Care Ward: A Quality Improvement Project.

Background Medicines reconciliation (MR) provides an accurate list of a patient's medications, but its clinical utility depends on the reconciled list being accurately translated into the inpatient prescription and intentional changes being documented. Older patients are particularly vulnerable because of polypharmacy, multimorbidity, and frequent transitions between care settings. Objective The primary objective of this study is to assess regular medication prescribing against the completed MR list after transfer to an elderly care ward, with a target of a 50% relative reduction in patients with at least one clinically important unexplained discrepancy. A secondary objective was to assess the documented rationale for intentional medication changes. Materials and methods A retrospective quality improvement project was conducted at a district general hospital in England. During the baseline period (May-July 2025), 75 patient records were reviewed, of which 71 were included after excluding four without an MR list. Inpatient regular medication prescriptions were compared with the MR list, and the electronic patient record was reviewed for documented rationale. Discrepancies with a documented rationale were classified as intentional and were not counted as unexplained discrepancies. Minor discrepancies involving low-consequence medications were excluded from the primary analysis. The intervention consisted of a resident doctor induction briefing on accessing and using the MR list and a workflow reminder poster in the doctors' room. A further 75 records were reviewed from September-November 2025, with 71 included after the same exclusions. Fisher's exact test and risk ratios with 95% confidence intervals (CIs) were calculated. Results Among the 71 patients analysed in each period, the proportion with at least one unexplained discrepancy fell from 21 (29.6%) to 15 (21.1%), a relative reduction of 28.6% (risk ratio 0.71, 95% CI 0.40-1.27; p=0.335). Among patients with clinically important discrepancies, the proportion for whom every discrepancy had documented rationale increased from 9 (30.0%) of 30 patients to 24 (61.5%) of 39 patients (risk ratio 2.05, 95% CI 1.13-3.74; p=0.015). Conclusion A low-cost educational and visual reminder intervention was associated with fewer unexplained discrepancies in regular medications and substantially better documentation of intentional medication changes. The reduction in unexplained discrepancies was not statistically significant and the pre-specified target of a 50% relative reduction was not achieved. Further cycles will aim to strengthen pharmacist-doctor communication and assess the severity of discrepancies.