Introduction of a Pre-admission Pharmacist Service Utilising the Surgical Ward Pharmacist

Background: The challenge with obtaining a best possible medication history (BPMH) post-surgery is the delay in clarifying medications due to decreased post-operative cognitive status and pain, which can lead to missed or late administration of medications. Studies have suggested that unintentional medication discrepancies at the time of admission are common in general medical patients. Objectives: To investigate if a pre-admission pharmacist completing BPMHs for adult elective surgery patients with planned overnight admission increases the proportion of patients with (i) a BPMH completed, (ii) medication reconciliation completed and (iii) all home medications charted correctly within 24 hours of admission. Methods: Patients in the pre-intervention group had a BPMH completed on admission as standard of care. Patients in the post-intervention group were contacted by the pre-admission pharmacist 1 to 3 business days prior to admission to complete a BPMH. The pre-admission pharmacist role was performed by a surgical ward pharmacist in addition to their daily workload. Descriptive statistics, Chi-squared test and Mann-Whitney U test were used to analyse the data. Results: The post-intervention group had more patients with a completed BPMH (47.2% vs 25.3%, P = .005), medication reconciliation (43.8% vs 15.5%, P = .0001) and all home medications charted correctly (36% vs 16.9%, P = .007) within 24 hours of admission compared with the pre-intervention group. Conclusion: The introduction of a pre-admission service utilising the surgical ward pharmacist increased the proportion of patients with a completed BPMH, medication reconciliation and home medications charted correctly within 24 hours of admission.