Impact of Clinical Pharmacy Residents on Medication Reconciliation upon Admission in a Tertiary Care Hospital

Medication errors represent a global issue that can adversely affect patients and healthcare systems. Inappropriate medication reconciliation (MedRec) is the leading cause of prescribing errors, with over 40% of such incidents. Evidence shows that clinical pharmacy resident-run MedRec programs can identify and resolve unintentional medication discrepancies (UMDs) in 60.2% of patients, demonstrating these services' potential impact on patient care. This study evaluated clinical pharmacy residents' impact on MedRec during their clinical rotations in a tertiary care hospital.

This retrospective, observational, single-center study was conducted from November 2021 to the end of March 2022 by four clinical pharmacy residents on adult patients aged 18 years or older who were admitted to the hospital within 48 hours. Data were obtained by using a MedRec form and the hospital's electronic medical record system during a 5-month period. The primary outcome was to measure clinical pharmacy residents' impact on the MedRec service by identifying the number and proportion of UMDs observed among admitted patients during residents' clinical rotations.

In total, 205 patients were included, with 193 UMDs identified. Most of the discrepancies were omissions (119 [62%]), followed by non-compliance (20 [11%]), commission (19 [9%]), and duplication (13 [7%]). Healthcare providers accepted 151 (86%) physician-directed interventions. Resumption of medication was the most common intervention, accounting for 66% of all interventions.

Clinical pharmacy residents significantly contribute to improving medication safety by detecting and resolving UMDs during patient admission. Their involvement highlights the value of pharmacist-led MedRec and supports its integration as a core element of residency training to reduce adverse drug events and improve outcomes.