Date of Award

Fall 2022

Project Type

Clinical Doctorate

College or School




Program or Major

Doctor of Nursing Practice

Degree Name


First Advisor

Marcy Ainslie


BACKGROUND: Medication errors are a prevalent patient safety concern across healthcare settings. High-quality medication reconciliation is an intervention and expected standard of care that can help to prevent adverse drug events. This quality improvement project focused on implementing a standardized medication reconciliation protocol on a short-stay psychiatric unit.

INTERVENTION: An evidence-based toolkit supported by the Agency for Healthcare Research and Quality (AHRQ), Medications at Transitions and Clinical Handoffs (MATCH) was selected as the framework for developing and implementing this protocol.

Congruent with the evidence-based toolkit recommendations, baseline data collection and needs assessment provided context for tailoring the intervention to the unit’s needs. A mixed-methods approach incorporated both qualitative and quantitative, varied sources of data from semi-structured staff interviews, workflow observation, manual retrospective chart reviews, and staff training attendance and pre-post test performance. The intervention included staff education and training on best practices for medication reconciliation and interviewing techniques; training for use of electronic health record features to capture completion; recommendations for policy revisions to support adherence and consistency; provision of a standardized workflow incorporating best practices for medication reconciliation, and a detailed recommendation of how to fully digitize this process to utilize a single source document when the technology becomes available.

RESULTS: The educational training sessions were attended by 57% of nurses employed on the unit. Manual retrospective chart reviews were completed at baseline and after providing the interventions. From baseline to post-intervention, there was a 9% decrease in the frequency of medication discrepancies. The results demonstrate a need for continual oversight and reinforcement of the electronic capture of medication reconciliations to support ongoing medication safety.

CONCLUSIONS: Persons with severe mental illness are particularly vulnerable for medication errors during periods of transitional care. Short-stay psychiatric admissions provide an opportunity to clarify, educate, and communicate medication regimes across care teams to improve care outcomes. Standardized medication reconciliation protocols during psychiatric stabilization stays can improve medication safety and patient care outcomes.