Pharmacist-led medication reconciliation upon discharge from the orthopedic surgery department

The pharmacist's role in medication reconciliation and patient counseling upon discharge from the orthopedic surgery department remains uncertain. The aim of this study was to assess the impact of a pharmacist-led medication reconciliation and patient counseling upon discharge from the orthopedic surgery department on the number of unintended medication discrepancies. This was a prospective, single-center, open-label, randomized controlled trial conducted over a 7-month period at a university medical center. The study included adult patients discharged from the orthopedic surgery department with at least one discharge medication. In the control arm, patients received the standard of care, while in the intervention arm, they received the standard of care in addition to incorporating a service provided by the pharmacy resident at discharge that consisted of performing medication reconciliation, providing patient counseling, then conducting telephone follow-up at day 3 post-discharge. The primary endpoint was the number of unintended discrepancies identified on day 30 post-discharge. Descriptive statistics were used to report all participants' responses. Pearson χ² test or Fisher's exact test, where the expected cell count < 5, were used to report the association between categorical variables. Results were assumed to be significant when p < 0.05 for all statistical analyses. The study included a total of 178 patients. For the primary endpoint on day 30 post-discharge, a total of 40 unintended discrepancies were identified in 29 (16.3%) patients. Around 28% of patients in the control group had a least one unintended medication discrepancy, compared to 4.5% patients in the intervention group (p < 0.001). The most common discrepancies consisted of medication commission (35%). Some unintended discrepancies were classified as potentially serious (10%). Pharmacist-led medication reconciliation upon discharge from the orthopedic surgery department was associated with a significant reduction in the number of unintended medication discrepancies.