Reducing errors through discharge medication reconciliation by pharmacy services.

Area of Science:

• Pharmacology
• Patient Safety
• Health Services Research

Background:

• Adverse drug events (ADEs) are a significant cause of hospital admissions.
• Medication discrepancies during care transitions, especially at discharge, contribute to ADEs.
• Medication reconciliation is crucial for preventing errors, with pharmacist involvement being key.

Purpose of the Study:

• To evaluate the effectiveness of integrating pharmacist review into the discharge medication reconciliation process.
• To determine if pharmacist intervention can identify and correct medication discrepancies.

Main Methods:

• Prospective data collection from internal medicine patients under hospitalist care.
• Chart review and patient interviews to identify medication lists.
• Pharmacist-led identification and categorization of medication discrepancies by potential adverse effect severity.

Main Results:

• 63 medication discrepancies were identified in 104 patients; 41% of patients had at least one discrepancy.
• Patients with 8 or more discharge medications faced a significantly higher risk of discrepancies (OR 8.5, p <0.001).
• Most discrepancies were of minimal (44.4%) or moderate (49.2%) risk for adverse effects.

Conclusions:

• Approximately 2 in 5 patients on the hospitalist service experienced medication discrepancies at discharge.
• Pharmacist intervention effectively identifies and corrects these discrepancies.
• Integrating pharmacists into the discharge process can help prevent avoidable adverse drug events.