Daily practice performance (Work-as-Done) compared to guidelines (Work-as-Imagined) of medication reconciliation at discharge: Outcomes of a FRAM study

Objectives: Performing medication reconciliation (MR) is an important safety initiative. However, its implementation is complex. We used the Functional Resonance Analysis Method (FRAM) to gain more understanding of healthcare professionals’ low compliance with the standards for MR by comparing Dutch guidelines and hospital protocols (Work-as-Imagined/WAI) with daily clinical practice (Work-as-Done/WAD). Methods: Nine cardiology and orthopaedics wards participated in this study. We applied the FRAM to construct several models to visualise MR at the point of discharge. WAI models were based on national guidelines and hospital protocols. Data to construct the WAD models were collected through semi-structured interviews with the healthcare professionals involved. Results: Sixty-three healthcare professionals were interviewed. These occasionally had to adjust their work in order to manage a lack of time or resources, resulting in variation in healthcare professionals’ performance. This had an impact upon the flow of the reconciliation process due to the interdependency of all the healthcare professionals involved. Conclusion: Collaboration between healthcare professionals is essential to ensure complete reconciliation for discharged patients. We identified a distinction between daily practice and both the guidelines and protocols followed. Future research should indicate the impact of specific variations in practice, and deviations from the protocols on medication safety, during reconciliation.