Discharge Reconciliation Research Articles

Benchmarking hospital clinical pharmacy practice using standardised key performance indicators (KPIs).

Background: Hospital pharmacy services support quality use of medicines and medication safety through clinical pharmacy activities such as medication reviews and patient education. These activities can be measured and monitored using evidence-based and standardised key performance indicators (KPIs), which highlight the value of pharmacy services. Standardisation of KPIs supports long-term benchmarking and inter- and intra-site comparisons to target key areas for improvement in clinical pharmacy services. Aim: To describe the type and frequency of clinical pharmacy activity across five hospitals within one metropolitan hospital district. Methods: Key Performance Indicator data were collected by pharmacists from five hospital sites at one metropolitan hospital district, in Queensland Australia. Data were collected over one week for the following clinical settings: inpatient, discharge, outpatient clinic, and the dispensary. Data were collected using a manual, paper-based data collection tool previously developed using a co-design process. Results: Across 11,215 inpatient encounters, hospital pharmacy services provided: best possible medication history (BPMH) within 24 h of admission: 69.5%; daily medication chart review: 57.2%; discharge education: 82.7%, discharge reconciliation: 88.2%; and provision of discharge medication record: 82.4%. Across 1,092 outpatient encounters, pharmacists documented BPMH for 33.3% of patients. Pharmacists identified a total of 5,009 drug-related problems (DRPs) across the data collection period, with the rate of identification highest in the outpatient clinic setting (64.8 per 100 patient reviews) followed by discharge (52.6 per 100 patient reviews) and then inpatient (48.1 per 100 patient reviews). Almost 20% of DRPs identified (n = 975) were high risk. Conclusion: Reporting and benchmarking clinical pharmacy activity through standardised KPIs supports opportunities to identify service improvements. Future research should focus on larger scale studies using routinely recorded data to monitor clinical pharmacy KPIs across all care settings.

Patient Experiences of Community Pharmacy Medication Supply and Medicines Reconciliation at Hospital Discharge: A Pilot Qualitative Study.

(1) Background: As part of the Scottish Government's five-year recovery plan to address the backlog in NHS care following the COVID-19 pandemic, community pharmacies in Scotland are planned to provide a Hospital Discharge Medicines Supply and Medicines Reconciliation Service. We aimed to qualitatively explore patients' experiences with this new service. (2) Method: Adult patients (≥18 years age) who consented to participate in the Community Pharmacy Hospital Discharge and Medicines Reconciliation Service were invited for an interview within 21 days of discharge from hospital. Qualitative, one-to-one, semi-structured patient interviews were conducted by telephone and audio-recorded using Microsoft Teams®. The interview audio recordings were transcribed verbatim and underwent thematic analysis. (3) Results: Twelve patients were interviewed, evenly split by sex and with a median age of 62 years (range 36 to 88 years). Our analysis generated main five themes: patient engagement, stakeholder communication, practical factors, human factors, and comparative experiences. Many of these were interdependent. (4) Conclusions: Patients appreciated that the service ensured a quicker discharge from hospital. Good stakeholder communication, practical factors (including choice, location, and the realities of obtaining their medication from the community pharmacy), and a pre-existing and trusted relationship in their usual community pharmacy were the key factors that regulated the patient experience. Generally, patients were positive about the introduction of this new service. However, the lack of a previous relationship or trust with a community pharmacy, and previous experiences with medication supply problems were factors which had the potential to negatively impact patient experiences.

Medication reconciliation and discharge communication from hospital to general practice: a quantitative analysis.

The aim of this study was to assess the quality of effective discharge communication to primary practice from a hospital that uses ieMR (integrated electronic Medical Record), a complete electronic prescribing/medical record platform. A retrospective quantitative analysis of 232 discharge encounters from a major tertiary hospital assessed the discharge summary quality; timeliness, completeness and medication information. Median time to discharge summary was 1day. 22.0% of discharge summaries were incomplete at 30days post discharge and 44.5% of discharge summaries were incomplete at 30days post discharge if discharged on a weekend compared to weekday (P-value=0.001). Rates of medication reconciliation were completed at approximately 35% at each point of the patient stay and 56.9% of patients had a GP discharge summary listing discharge medications. However, if certain progressive steps were completed (i.e. Home Medications recorded in ieMR, Discharge Reconciliation in ieMR, and Patient Discharge Medication Record in eLMs (Enterprise-wide Liaison Medication System)), then, the 'Medications on Discharge' was significantly more likely to be present in the discharge summary, at rates of 70.1%, 85.9%, and 98.6% respectively (P-value=0.007, <0.001, <0.001). Conversely not doing these steps dropped rates of having medications listed in the discharge summary to 50.0%, 40.3% and 34.1% respectively. This study assessed current discharge summary quality since the introduction of electronic medical records. It demonstrated the significant value of correct use of electronic programs, including performing all crucial steps of reconciliation. Targeted interventions in future studies that rectify the shortfalls in discharge communication are warranted.

Triaging Admissions: A Survey of Internal Medicine Resident Experiences and Perceptions and Recommendations on Inpatient Triage Education

Transitions of care (TOCs) have been identified as critically important for patient safety. The Joint Commission Center for Transforming Healthcare, World Health Organization, and national societies have emphasized the importance of TOCs.1,2 The literature on TOCs has focused on inpatient to outpatient transitions, and handovers within the hospital.3 Inpatient to outpatient TOCs emphasize communication at discharge and medicine reconciliation to prevent adverse events and readmissions.4 In contrast, the process of admitting patients from outpatient to inpatient settings has only recently begun to receive attention.

Medication Errors and Type 2 Diabetes Management: A Qualitative Exploration of Physicians' Perceptions, Experiences and Expectations From Quetta City, Pakistan.

BackgroundType 2 Diabetes-related medication errors are frequently reported from the hospitals and consequently are of major concern. However, such reports are insufficient when developing healthcare settings are pursued in literature. Keeping this inadequacy in mind, we therefore aimed to explore physicians' perceptions, experiences and expectations of medication errors when managing patients with Type 2 Diabetes Mellitus.MethodsA qualitative design was adopted. By using a semi-structured interview guide through the phenomenology-based approach, in-depth, face-to-face interviews were conducted. Physicians practicing at the medicine ward of Sandeman Provincial Hospital, Quetta, were purposively approached for the study. All interviews were audio-taped, transcribed verbatim, and were then analyzed for thematic contents by the standard content analysis framework.ResultsAlthough the saturation was reached at the 13th interview, we conducted additional two interviews to ensure the saturation. Fifteen physicians were interviewed, and thematic content analysis revealed six themes and nine subthemes. Mixed conceptualization and characterization of medication errors were identified. Medication errors were encountered by all physicians however poor understanding of the system, deficiency of logistics and materials were rated as barriers in reporting medication errors. Among contributors of medication errors, physicians themselves as well as dispensing and patient-related factors were identified. Physicians suggested targeted training sessions on medication error-related guidelines and reporting system. Parallel, establishment of an independent unit, involving the pharmacists, and strict supervision of paramedics to minimize medication errors was also acknowledged during data analysis.ConclusionWith a longer life expectancy and a trend of growing population, the incidences of medication errors are also expected to increase. Our study highlighted prescribing, dispensing and administration phases as contributing factors of medication errors. Although, physicians had poor understanding of medication errors and reporting system, they believed getting insights on guidelines and reporting system is essential. A review of admission and discharge reconciliation must be prioritized and a culture of teamwork, communication and learning from mistakes is needed.

Rates of discharge reconciliation completion following the rollout of an electronic prescribing interface in two large Queensland hospitals

Rates of discharge reconciliation completion following the rollout of an electronic prescribing interface in two large Queensland hospitals

Barriers and facilitators of medicines reconciliation at transitions of care in Ireland \u2013 a qualitative study

BackgroundMedication error at transitions of care is common. The implementation of medicines reconciliation processes to improve this issue has been recommended by many regulatory and safety organisations. The aim of this study was to gain insight from healthcare professionals on the barriers and facilitators to the medicines reconciliation implementation process.MethodsSemi-structured interviews were conducted in Ireland with a wide range of healthcare professionals (HCPs) involved with medicines reconciliation at transitions of care. Thematic analysis was undertaken using an adaptation of a combined theoretical framework of Grol, Cabana and Sluisveld to classify the barriers and facilitators to implementation of medicines reconciliation.ResultsThirty-five participants were interviewed, including eleven community pharmacists (CPs), eight hospital pharmacists (HPs), nine hospital consultants (HCs), five general practitioners (GPs), and two non-consultant hospital doctors (NCHDs). Themes were categorized into barriers and facilitators. Barriers included resistance from existing professional cultures, staff interest and training, poor communication and minimal information and communications technology (ICT) support. Solutions (facilitators) suggested included supporting effective multidisciplinary teams, greater involvement of pharmacists in medicines reconciliation, ICT solutions (linked prescribing databases, decision support systems) and increased funding to provide additional (e.g. admission and discharge reconciliation) and more advanced services (e.g. community pharmacist delivered medicines use review).ConclusionsMedicines reconciliation is advocated as a solution to the known problem of medication error at transitions of care. This study identifies the key challenges and potential solutions that policy makers, managers and HCPs should consider when reviewing the practices and processes of medicines reconciliation in their own organisations.

Implementation and Assessment of a Pharmacy-Led Inpatient Transitions of Care Program.

To evaluate pharmacist involvement in the inpatient transition of care (TOC) process for patients hospitalized with type 1 diabetes mellitus, type 2 diabetes mellitus, or chronic obstructive pulmonary disease. A pharmacist screened patients admitted with one or more of the qualifying conditions within 48 hours of admission to perform medication reconciliation. During medication reconciliation, the pharmacist removed any duplicate or nonindicated medications and added any omitted medications. The pharmacist also reviewed the discharge summary to ensure medication optimization upon discharge. Pharmacist involvement in the admission and discharge reconciliation processes of the 50 identified patients was 100% and 44%, respectively. A medication-related problem was identified in 96% (n = 48) of patients, representing 338 pharmacist-mediated interventions with an average of 6.8 ± 4.0 (range 0-16) interventions per patient. Of those 338 interventions, 298 drug discrepancies were identified and corrected, with an average of 6.0 ± 3.7 (range 0-15) discrepancies per patient. Average time spent was 66 ± 22 (range 30-130) minutes with each patient. Of the 50 patients enrolled, 12 were readmitted within 30 days. This pilot study demonstrated an improved medication reconciliation process with pharmacist involvement, expanding the body of evidence that pharmacists can enhance TOC management in an inpatient setting. These results highlight the utility of a pharmacist in the implementation and refinement of TOC services and provides impetus for a team-based approach when patients experience a TOC.

Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project.

Background and ObjectiveMany countries require hospitals to implement medication reconciliation for accreditation, but the process is resource-intensive, thus adherence is poor. We report on the impact of prepopulating and aligning community and hospital drug lists with data from population-based and hospital-based drug information systems to reduce workload and enhance adoption and use of an e-medication reconciliation application, RightRx.MethodsThe prototype e-medical reconciliation web-based software was developed for a cluster-randomized trial at the McGill University Health Centre. User-centered design and agile development processes were used to develop features intended to enhance adoption, safety, and efficiency. RightRx was implemented in medical and surgical wards, with support and training provided by unit champions and field staff. The time spent per professional using RightRx was measured, as well as the medication reconciliation completion rates in the intervention and control units during the first 20 months of the trial.ResultsUsers identified required modifications to the application, including the need for dose-based prescribing, the role of the discharge physician in prescribing community-based medication, and access to the rationale for medication decisions made during hospitalization. In the intervention units, both physicians and pharmacists were involved in discharge reconciliation, for 96.1% and 71.9% of patients, respectively. Medication reconciliation was completed for 80.7% (surgery) to 96.0% (medicine) of patients in the intervention units, and 0.7% (surgery) to 82.7% of patients in the control units. The odds of completing medication reconciliation were 9 times greater in the intervention compared to control units (odds ratio: 9.0, 95% confidence interval, 7.4-10.9, P < .0001) after adjusting for differences in patient characteristics.ConclusionHigh rates of medication reconciliation completion were achieved with automated prepopulation and alignment of community and hospital medication lists.

Appropriate Reconciliation of Cardiovascular Medications After Elective Surgery and Postdischarge Acute Hospital and Ambulatory Visits.

To describe appropriate discharge reconciliation of cardiovascular medications and assess associations with postdischarge healthcare utilization in surgical patients. Retrospective cohort study from January 2007 to December 2011. An academic medical center. Seven hundred and fifty-two adults undergoing elective noncardiac surgery and taking antiplatelet agents, beta-blockers, renin-angiotensin system inhibitors, or statin lipid-lowering agents before surgery. Primary predictor: appropriate discharge reconciliation of preoperative cardiovascular medications (continuation without documented contraindications). Primary outcomes: acute hospital visits (emergency department visits or hospitalizations) and unplanned ambulatory visits (primary care or surgical) at 30 days after surgery. Preoperative medications were appropriately reconciled in 436 (58.0%) patients. For individual medications, appropriate discharge reconciliation occurred for 156 of the 327 patients on antiplatelet agents (47.7%), 507 of the 624 patients on beta-blockers (81.3%), 259 of the 361 patients on renin-angiotensin system inhibitors (71.8%), and 302 of the 406 patients on statins (74.4%). In multivariable analyses, appropriate reconciliation of all preoperative medications was not associated with acute hospital (adjusted odds ratio [AOR], 0.94; 95% confidence interval [CI], 0.63-1.41) or unplanned ambulatory visits (AOR, 1.48; 95% CI, 0.94-2.35). Appropriate reconciliation of statin therapy was associated with lower odds of acute hospital visits (AOR, 0.47; 95% CI, 0.26-0.85). There were no other statistically significant associations between appropriate reconciliation of individual medications and either outcome. Although large gaps in appropriate discharge reconciliation of chronic cardiovascular medications were common in patients undergoing elective surgery, these gaps were not consistently associated with postdischarge acute hospital or ambulatory visits.

Benefits of subspecialty adherence after asthma hospitalization and patient perceived barriers to care

BackgroundComparative studies have demonstrated that asthma education to pediatric patients decreases average hospital usage and that allergy specialists provide stronger asthma education and more improved outcomes. ObjectiveTo evaluate the real-world benefits of allergy subspecialty involvement outside inpatient consultation and the impediments for patients in establishing allergy subspecialty care. MethodsThe study population was composed mostly of minority children 0 to 18 years old seen at a large university-affiliated stand-alone children's hospital who had a hospital discharge diagnosis of asthma from 2009 to 2013. The retrospective portion of the study compared all variables pertaining to asthma, teaching, and discharge reconciliation for the following subgroups: patients recommended to allergy and immunology (AI) follow-up who adhered to the appointment (adherent), patients recommended to AI follow-up who did not adhere (nonadherent), and patients not recommended to AI follow-up (non-referred). In the phone interview portion of the study, the nonadherent patients were contacted to identify barriers to AI follow-up. ResultsOf the referred sample, the adherent group had significantly fewer visits to the pediatric intensive care unit, days in the pediatric intensive care unit, and days in the hospital. Providing more specific hospital discharge instructions increased AI follow-up and hospital teaching given on the baseline admission decreased hospital visits. Phone interviews showed that nonadherent patients most commonly missed follow-up because the parents believed it unnecessary because their child showed acute improvement or from advice from their primary care physician. ConclusionThese results showed improvement in outcomes for patients who attended AI follow-up and specifically identified key barriers that could be addressed in a standardized form to prevent nonadherence in the future.

Pharmacist-Provided Medication Management in Interdisciplinary Transitions in a Community Hospital (PMIT).

Medication management during transitions of care (TOC) impacts clinical outcomes. Published literature on TOC implementation is increasing, but data remains limited regarding the optimal role for the inpatient pharmacist, particularly in the community health setting. To evaluate the impact of a dedicated inpatient TOC pharmacist on re-presentations following discharge. This is a prospective study with historical control. All adult patients discharging home from study units were eligible. The TOC pharmacist (1) reviewed medication history and admission reconciliation, (2) met the patient/caregiver to assess barriers, (3) reviewed discharge reconciliation, (4) performed discharge education, and (5) communicated with next level of care. The primary outcome was 30 day re-presentation rate. Secondary outcomes included 60, 90, and 365 day re-presentation rates. IRB approval was obtained. Three hundred and eighty four patients met inclusion criteria. When compared to 1,221 control patients, the intervention had an 11% absolute and 50.2% relative reduction in 30 day re-presentation rate (OR 0.43, 95% CI 0.30-0.61, NNT 9). Reductions in re-presentations at 60, 90 and 365 days remained statistically significant. Utilization avoidance was $786,347. For every $1 invested in pharmacist time, $12 was saved. The TOC pharmacist made a total of 904 interventions (mean 2.4 per patient). This study provides new information from previous studies and represents the largest study with significant and sustained reductions in re-presentations. Integrating a pharmacist into an interdisciplinary team for medication management during TOC in a community health system is beneficial for patients and financially favorable for the institution.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

ObjectivesReliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process...

Impact of pharmacist‐led medication reconciliation on admission using electronic medical records on accuracy of discharge prescriptions

AbstractBackgroundUnintentional medication errors are common at hospital discharge and have the potential to cause significant patient harm. Current electronic medical records systems offer the facility to change the process of medication reconciliation by pharmacists.AimTo test the impact of pharmacist‐led medication reconciliation at admission recorded on the electronic medication form, on the timeliness and accuracy of discharge prescriptions.MethodA prospective pre‐ and post‐interventional observational study was carried out from June to October 2013 at two district hospitals. Pharmacists recorded admission medication using National Medication Management Plan (phase 1) and the electronic medication form in patients’ electronic medical records (phase 2). Data collected included time taken for the medical officer to complete the medication form in electronic medical records, the number of times the medical officer was contacted by the pharmacist completing the discharge reconciliation and unintentional discharge medication discrepancy types.ResultsIn total 118 patients were included: 66 patients in phase 1 and 52 in phase 2. Data were analysed using chi‐squared test, Fisher's exact test and Mann–Whitney test. There was a significant (33–13%, p &lt; 0.0001) reduction in the proportion of medication orders with a discrepancy. This was because of the significant (25.5–1.9%, p &lt; 0.0001) reduction in discrepancies relating to patients’ usual medication. Time taken for the medical officer to complete the medication form in electronic medical records decreased from 37 s/item (interquartile range, 29–48; n = 51) to 21 s/item (interquartile range, 11–35; n = 35) (p &lt; 0.001). The number of telephone calls to medical officers decreased from 95 to 73%.ConclusionThis integrated approach to medication reconciliation has highlighted patient safety benefits, and reduced medical and pharmacy workload.

Prevalence of potentially inappropriate medication in hospitalized elderly patients by using explicit criteria

Potentially inappropriate medication (PIM) prescribing in older adults is quite prevalent and is associated with an increased risk for adverse drug events, morbidity, and utilization of health care resources. The aim of this study was to determine the prevalence and type of PIM in polypharmacy elderly patients on admission and discharge and the factors associated with their prescription. Just as the applicability of various explicit criteria selected from the literature and adapted to our area. We performed a cross-sectional study for 12 months (March 2010-February 2011) on 179 polypharmacy elderly patients admitted to an Internal Medicine Department. We created a list of 50 PIM using a Delphi approach based on previous published criteria (Beers, Stopp, BMC and Priscus). Through patient interviews, review of medical records and discharge reconciliation report, we identified the prevalence of PIM in the patients. We also analyzed the relationship between different factors and the prescription of PIM. The prevalence of patients with PIM on admission and discharge were 71% and 48%, respectively. Out of the 50 selected PIM, 27 and 26 were detected on admission and discharge, respectively (55.5% and 57.69% included on STOPP criteria). We detected two factors associated with PIM prescription at discharge: severe-total dependence (OR = 1.8) and prescription of more than 11 drugs (OR = 2). PIM prevalence in our population is very high (70%), especially at hospital admission. These findings support the need for measures aimed at improving the quality of prescriptions, especially on dependent patients with polypharmacy.

Embedding pharmacists throughout a health system

Pharmacists are everywhere at Froedtert & the Medical College of Wisconsin Froedtert Hospital. From the moment patients enter the hospital to the moment they leave, pharmacists play an active role in managing and monitoring medications.

Dynamic duo leads med rec at the University of Kansas Hospital

Great collaborators in history—like Orville and Wilbur Wright, Watson and Crick, and Simon and Garfunkel shared a passion for innovation and creativity. So too do Samaneh T. Wilkinson, PharmD, MS, Assistant Director of Pharmacy at the University of Kansas Hospital in Kansas City, KS, and her boss Rick Couldry, BSPharm, MS, Director of the Pharmacy Department. Together, this pair has forever changed pharmacy practice at the hospital by implementing a pharmacist-facilitated medication reconciliation program where 95% of patients have direct face-to face interactions with a member of the pharmacy staff to discuss their medications.

Standardization: Novant’s secret for improving medication safety

Medication safety touches every action, initiative, and decision across a hospital system, from the clinical floors to operations and leadership. Elizabeth McGowan, PharmD, believes that the door is wide open with unlimited possibilities for health-system pharmacists to be involved with medication safety on every level, from the pharmacy to the patient bedside.

Using novel Canadian resources to improve medication reconciliation at discharge: study protocol for a randomized controlled trial

BackgroundAdverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem.Methods/DesignParticipants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units.DiscussionThe goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors.Trial registrationNCT01179867

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11). Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.