Medication Reconciliation Optimization: Cleaning up the wRECk


UC Davis Medical Center found that medication errors and discrepancies were widely prevalent at their institution. In line with studies from other institutions, up to 70% of patients have errors on their medication lists when admitted to the hospital. Their preliminary assessments were demonstrated with patients averaging over 5 discrepancies per admission. These discrepancies are carried downstream throughout hospitalization with impacts felt during transitions of care. The literature suggests that 0.9% of discrepancies lead to serious patient harm. They sought out to improve the medication reconciliation process at their institution using quality improvement principles and partnering with other institutions as part of the Medication Reconciliation Quality Improvement Study (MARQUIS).

Using a series of Quality Improvement (QI) principles, engaging executive and front-line staff, and leveraging existing resources, they were able to achieve a 64 % relative reduction in medication discrepancies compared to controls and reduce clinically significant medication discrepancies to less than 1 per patient. In addition, focusing their multi-bundle interventions on higher acuity, resource heavier medical patients resulted in reductions of lengths of stay, cost, and readmissions. Based on these results, the intervention expanded hospital-wide in January 2019.  UC Davis has been recognized nationally for the comprehensive intervention and were instrumental in the passing of California State Senate Bill 1254, medication histories for high risk patients.


  • Discuss methods to develop and identify a team to spearhead the necessary change in culture to be successful in Transitions of Care (TOC) and medication reconciliation changes
  • Explain the steps required to engage the C-suite, physicians and staff to change the culture towards TOC and medication reconciliation
  • List several interventions that have been successful in improving the TOC and medication reconciliation implementation process

Date and Time

Thursday, May 14, 2020 from 10:00am-11:00am Pacific


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Sarah A. Bajorek, PharmD, BCACP

Pharmacy Supervisor for Transitions of Care and Medication Reconciliation
UC Davis Health

Dr. Bajorek is the Pharmacy Supervisor for Transitions of Care and Medication Reconciliation at UC Davis Health and an Assistant Clinical Professor with UC San Francisco’s School of Pharmacy. She completed a Pharmacy Practice residency at UC Davis and a specialty residency in Transitions of Care at UC San Diego. Her research interests include medication reconciliation, safe and effective transitions to post-acute care settings, and quality improvement. She successfully implemented the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) 2 best practices, which were instrumental in changing the culture surrounding medication history and medication reconciliation at UC Davis. Because of her outstanding contributions in medication reconciliation, she was awarded the UC Davis Chief of Staff award in 2019.

Mithu Molla, MBA, MD

Hospitalist, Internal Medicine
UC Davis Health

Dr. Molla is a Health Sciences Clinical Professor of Medicine at UC Davis School of Medicine and currently  serves as Division Chief for Hospital Medicine at UC Davis Medical Center. His interests include leadership development, resident and student education in hospital medicine. He is involved in numerous hospital quality initiatives, hospital operations, and practice management, including medication management and medication reconciliation. Dr. Molla completed his medical degree at West Virginia University and went on to complete residency training in Internal Medicine at George Washington University, where he subsequently also received a Master’s degree in Business Administration.