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Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study
  1. Jeffrey L Schnipper1,2,3,
  2. Harry Reyes Nieva2,
  3. Meghan Mallouk4,
  4. Amanda Mixon5,6,
  5. Stephanie Rennke7,
  6. Eugene Chu8,
  7. Stephanie Mueller1,2,3,
  8. Gregory (Randy) R Smith Jr9,
  9. Mark V Williams10,
  10. Tosha B Wetterneck11,
  11. Jason Stein12,
  12. Anuj Dalal1,2,3,
  13. Stephanie Labonville13,
  14. Anirudh Sridharan14,
  15. Deonni P Stolldorf15,
  16. E John Orav2,16,
  17. Brian Levin2,
  18. Marcus Gresham2,
  19. Cathy Yoon2,
  20. Jenna Goldstein4,
  21. Sara Platt4,
  22. Christopher Tugbéh Nyenpan4,
  23. Eric Howell17,18,
  24. Sunil Kripalani5,19,
  25. and MARQUIS2 Site Leaders
  26. for the MARQUIS2 Study Group
      1. 1 Hospital Medicine Unit, Brigham Health, Boston, MA, USA
      2. 2 Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
      3. 3 Harvard Medical School, Boston, MA, USA
      4. 4 Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
      5. 5 Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
      6. 6 Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
      7. 7 Division of Hospital Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
      8. 8 Division of Hospital Medicine, Parkland Health and Hospital System and Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, TX, USA
      9. 9 Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
      10. 10 Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
      11. 11 Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
      12. 12 1Unit, Atlanta, GA, USA
      13. 13 Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
      14. 14 Howard County General Hospital Inc, Columbia, MD, USA
      15. 15 School of Nursing, Vanderbilt University, Nashville, TN, USA
      16. 16 Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
      17. 17 Society of Hospital Medicine, Philadelphia, PA, USA
      18. 18 Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
      19. 19 Vanderbilt Center for Clinical Quality and Implementation Research, Nashville, TN, USA
      1. Correspondence to Dr Jeffrey L Schnipper, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; jschnipper{at}


      Background The 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.

      Methods We 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.

      Results A 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.

      Conclusion A 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.

      • medication reconciliation
      • patient safety
      • healthcare quality improvement
      • transitions in care
      • pharmacists

      Data availability statement

      Data are available on reasonable request.

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      • Twitter @drjschnip, @harryreyesnieva, @DrStephMueller, @research_dee, @chrisnyenpan

      • Collaborators MARQUIS2 site leaders: Sanchita Sen, Samer Badr, Michelle Murphy, Corrie Vasilopoulos, Tara Vlasimsky, Christine Roussel, Olugbenga Arole, Loredana Diana Berescu, Arif Arifuddowla, Hattie Main, Susan Pickle, Cristy Singleton, Brenda Asplund, Andrea Delrue, Andrea Forgione, Colleen Shipman, Luigi Brunetti, Hina Ahmed, Adrian Gonzales, Mithu Molla, Sarah Bojerek, Andrea Nguyen, Robert El-Kareh, Kyle Koenig, Loutfi Succari, Scott Kincaid, Pamela Proctor, Robert Pendleton, Amy Baughman, Kimberly Boothe, Katarzyna Szablowski, Olukemi Akande, Eric Tichy.

        MARQUIS2 Study Group: Chi Zheng, Ryan Centafont, Regina Jahrstorfer, Lisa Jaser, Isha John, Margaret Curtin, Jenna Swindler, Joe Marcus, Robert Osten, Tian Yaw, Zainulabdeen Al-Jammali, Nancy Doherty, Brandi Hamilton, Magdee Hugais, Samson Lee, Paul Sabatini, Eddie Eabisa, Jennifer Mello, Julianna Burton, Edward Fink, Anthony Biondo, Trina Huynh, Ken Kormorny, Adonice Khoury, Kathryn Ruf, Dwayne Pierce, Chadrick Lowther, Karli Edholm, Shantel Mullin, Nicole Murphy, Jeni Norstrom, Laura Driscoll, Maribeth Cabie, Andrew Cadorette, Sara John, Amy D’Silva and Lionel Picot-Vierra.

      • Contributors All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline, individually or as a group.

      • Funding This study was funded by Agency for Healthcare Research and Quality (K01HS025486, R18 HS023757); National Center for Research Resources (UL1 RR024975-01); US Department of Veterans Affairs (12-168); and National Center for Advancing Translational Sciences (2 UL1 TR000445-06).

      • Competing interests JLS has received funding from Mallinckrodt Pharmaceuticals for an investigated-initiated study of opioid-related adverse drug events. JLS and AM received remuneration from American Society of Health-System Pharmacists (ASHP) to develop their best possible medication history training curriculum.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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