Identified Medication Discrepancies Research Articles

Assessment of medication discrepancy, medication appropriateness, and cost analysis among patients with pediatric nephrotic syndrome: An ambispective cohort observational study

BackgroundNephrotic syndrome (NS) is a commonly encountered chronic kidney disease in pediatric populations, with South Asian children being at high risk and requiring long-term pharmacological management. Thus, identifying medication discrepancies and evaluating the appropriateness of therapy and its economic burden are vital for inpatient management. The aim of the study was to assess medication reconciliation, medication appropriateness, and cost analysis in NS cases. MethodsAn ambispective cohort observational study was carried out with 150 NS patients where medication discrepancies were identified retrospectively and prospectively using the best possible medication history and following up patients correspondingly. Further, the Medication Appropriateness Index and cost variation analysis were used to assess the prescribed therapy and cost analysis, respectively. ResultsOut of 150 patients with NS included, 67.3% were male and the mean age was 7.2 years. In total, 36.7% medication discrepancies were found at baseline and 6% discrepancies at follow-up. The majority of discrepancies were unintentional and due to dosing error both at baseline and follow-up. Further, in only 2% of the patients was there inappropriately prescribed medication, and the majority of patients spent between INR (Indian Rupees) 500 and 1000. ConclusionChronic conditions like NS require continuous monitoring by the specialist pediatric clinical pharmacist, who can contribute significantly by minimizing the medication discrepancies, by assessing the appropriateness of therapy, and lessening the economic burden.

From Inaccuracy to Insight: Identifying Medication Discrepancies through Observational Reconciliation at a Tertiary Care Hospital, Bhimavaram of Andhra Pradesh

Background: Medication reconciliation is the process of examining the patient's entire medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care. This helps to prevent unintentional inconsistencies across transitions in medical care. Medication reconciliation protects patients from medication side effects while ensuring that they receive standard care. It serves as the baseline from which therapeutic interventions are developed, drug treatment is continued upon admission, and self-care is continued upon release. Objectives: Determining the frequency and kinds of discrepancies discovered during medication reconciliation was the main goal of this study. Determining the effect of medication reconciliation to assess the possible seriousness of medication inconsistencies and ascertain the drug's role in medication errors was the secondary goal. Methodology: In the inpatient units of a tertiary care hospital in the West Godavari District, a prospective, observational study on medication reconciliation was conducted for six months. Results: Of the 385 patients that made up this study, 224 (58.18%) were males and 161 (41.8%) were females. In 169 (43.89%) of the patients, medication discrepancies were detected. There were inconsistencies discovered at several transition points: 50 disparities were detected at admission, 50 during the transfer phase, and 17 on the discharge. Conclusion: A multi-centric assessment including parameters like the percentage of inpatients encountering at least one major medication error would be intriguing. This may support the idea that drug reconciliation is crucial for patient safety.

Medication Reconciliation Practices in Two Multispeciality Hospitals

Abstract: Background: Medication errors are common and can compromise patient safety. Commonly seen at discharge, they can be identified and resolved even during admission. Medication reconciliation is recommended to prevent errors arising from medication discrepancies. Aim: To conduct medication reconciliation in two multispeciality hospitals and classify the identified medication discrepancies according to their potential to cause harm. Materials and Methods: This prospective interventional study was carried out in medicine and surgery departments of two urban hospitals over a period of six months. Patients who satisfied the criteria were enrolled and medication reconciliation was performed. Interventions were provided whenever necessary. The identified discrepancies were then given to an expert panel for classifying them based on their potential to cause harm. Results: 580 medication discrepancies were identified from a total 372 patients, drug interaction (n=345, 61.6%) was the most commonly observed discrepancy, followed by omission error (n=127, 12.9%). The medication discrepancies observed from both the hospitals were found to be statistically not significant (p=0.246). From a total of 580 discrepancies, 454 (78.27%) discrepancies were Significant, 80 (13.79%) Serious and 46 (7.93%) Not Significant. Conclusion: The results of our study show that there are discrepancies in medication use when the patient transitions in a hospital. It is recommended that medication reconciliation practices be performed by clinical pharmacist during the hospital stay to ensure continuity of healthcare and for patient safety. An electronic medical record capable of capturing and continuously updating medication information may be a long-term solution. To achieve this, professional development of clinical pharmacists is of paramount importance. Keywords: Medication reconciliation, Clinical pharmacist, Medication discrepancies, Medication errors.

Improving the discharge medication reconciliation process for an inpatient hematologic malignancies service by utilizing a pharmacist-facilitated workflow

BackgroundThere is an opportunity for pharmacists to play a greater role during discharge medication reconciliation (MR), particularly in the oncology setting. ObjectivesThis initiative aims to decrease the number of medication discrepancies that occur during discharge MR and improve physician satisfaction with the discharge MR process for patients discharged from an inpatient adult hematologic malignancies (HM) service. Practice descriptionPatients on the HM service at Sibley Memorial Hospital, a community hospital located in Washington, DC, are co-managed by hospitalists and HM oncologists. The care team for the service also includes nursing staff and a clinical pharmacist. Practice innovationThe HM service piloted a pharmacist-facilitated workflow that involved the clinical pharmacist reconciling inpatient and outpatient medications prior to discharge, reviewing the discharge MR with the HM oncologist, and pending the discharge MR in the electronic medical record for the discharging hospitalist to review and sign. Evaluation methodsPrior to pilot implementation, discharge MRs of patients discharged from the HM service from November 2021 to December 2021 were analyzed by a pharmacist to identify medication discrepancies through retrospective chart review. This process was repeated to analyze pharmacist-facilitated discharge MRs for discrepancies for patients discharged between December 2021 to April 2022. Physician satisfaction with the process was assessed via survey pre and post-pilot. ResultsA total of 30 and 37 discharge MRs were analyzed pre- and post-pilot, respectively. There were 19 medications discrepancies identified in the pre-pilot group and 6 discrepancies noted in the post-pilot group (P=0.038). Median physician satisfaction with the process was found to be 3.3 pre-pilot, and 5 post-pilot (on a scale of 1-5, with 5 being very satisfied). ConclusionA pharmacist-facilitated workflow for discharge MR increased the accuracy of the discharge MR for patients on the HM service and improved physician satisfaction with the discharge MR process.

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit.

Minimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists. We assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team. In this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions). After the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p<0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p=0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p=0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month. The implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.

Medication reconciliation—is it possible to speed up without compromising quality? A before–after study in the emergency department

ObjectiveThe aim of this study was to investigate whether it was possible to decrease the time used for medication reconciliation (MR) in the emergency department without compromising quality. A more...

Risk factors for clinically relevant deviations in patients\u2019 medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting

Background Personal health records have the potential to identify medication discrepancies. Although they facilitate patient empowerment and broad implementation of medication reconciliation, more medication discrepancies are identified through medication reconciliation performed by healthcare professionals. Aim We aimed to identify the factors associated with the occurrence of a clinically relevant deviation in a patient’s medication list based on a personal health record (used by patients) compared to medication reconciliation performed by a healthcare professional. Method Three- to 14 days prior to a planned admission to the Cardiology-, Internal Medicine- or Neurology Departments, at Amphia Hospital, Breda, the Netherlands, patients were invited to update their medication file in their personal health records. At admission, medication reconciliation was performed by a pharmacy technician. Deviations were determined as differences between these medication lists. Associations between patient-, setting-, and medication-related factors, and the occurrence of a clinically relevant deviation (National Coordinating Council for Medication Error Reporting and Prevention class ge E) were analysed. Results Of the 488 patients approached, 155 patients were included. Twenty-four clinically relevant deviations were observed. Younger patients (adjusted odds ratio (aOR) 0.94; 95%CI:0.91–0.98), patients who used individual multi-dose packaging (aOR 14.87; 95%CI:2.02–110), and patients who used ge 8 different medications, were at highest risk for the occurrence of a clinically relevant deviation (sensitivity 0.71; specificity 0.62; area under the curve 0.64 95%CI:0.52–0.76). Conclusion Medication reconciliation is the preferred method to identify medication discrepancies for patients with individual multi-dose packaging, and patients who used eight or more different medications.

Implementing Student Pharmacist- Led Health Outreach Events at Long-term Care Facilities in a Medically Underserved Community.

To describe the process of creating precepted, student pharmacist-led health outreach events at long-term care facilities and to describe the lessons learned during the implementation process. Yakima, Washington, a medically underserved area. Pharmacy students, supervised by pharmacist preceptors, conducted health outreach events at local long-term care facilities on a rotating monthly basis. These students provided comprehensive medication reviews, blood pressure screenings, and blood glucose screenings. Pharmacists providing medication reviews at long-term care facilities where residents manage their medications can address polypharmacy by identifying medication discrepancies, determining the effectiveness of treatment, and improving patient outcomes. Conducting health outreach events with pharmacy-student involvement includes the added benefit of providing students with the opportunity to gain hands-on experience before beginning their clinical Advanced Pharmacy Practice Experience (APPE) rotations and practice skills described in the American Society of Consultant Pharmacists Geriatric Pharmacy Curriculum Guide and Pharmacist's Patient Care Process. Nineteen health outreach events at long-term care facilities were held, and more than 100 residents participated annually. Students coordinated events successfully after developing a standardized set of questions, which was necessary for planning, and identifying someone to act as an event coordinator, recruiting students and ensuring they were appropriately trained, and creating a monitoring form to be filled in and shared with the participant. Students learned key lessons including naming the events appropriately to avoid confusion, understanding that not all long-term care facilities are alike, deciding how many students to recruit from each cohort to participate in events, optimizing the preceptor-to- student ratio, and ensuring preceptors were thorough in their oversight of students. This work described the implementation of health outreach events conducted by supervised student pharmacists at long-term care facilities. Health outreach events could be conducted by other colleges or facilities to provide important medication review and health screening services for long-term care facilities' residents, as well as providing student pharmacists with opportunities to learn and practice patient-care related skills.

Obtaining the Best Possible Medication History at Hospital Admission: Description of a Pharmacy Technician-Driven Program to Identify Medication Discrepancies

Purpose: Describe the process of obtaining the best possible medication history (BPMH) by Certified Pharmacy Technicians (CPhTs) on hospital admission to identify medication discrepancies. Methods: Cross-sectional, descriptive study conducted between December 2016 and June 2017 at a quaternary center in New York, including all patients 18 years and older admitted to the medicine service through the Emergency Department (ED) and seen by a CPhT. CPhTs obtained the BPMH using a systematic approach involving a standardized interview, checking medications with secondary sources and updating the electronic health record (EHR). Medication discrepancies were identified and categorized by type and risk. Summary statistics were provided as average and standard deviation (SD) for continuous variables, and as frequencies and percentages for categorical variables. Multivariable regression was used to test for associations between patient factors and presence of a medication discrepancy. Results: Of the 3,087 patient visits, the average age was 69 (SD 17.8), 54% were female (n = 1652) and 65% white (n = 2017); comorbidity score breakdown was: 0 (25%, n = 757), 1-2 (33%, n = 1023), 3-4 (23%, n = 699), > 4 (20%, n = 608). The average number of home and discharge medications were 10 (SD 6.1) and 10 (SD 5.4), respectively. The average time spent obtaining the BPMH was 30.6 minutes (SD 12.9). 69% of patients (n = 2130) had at least 1 discrepancy with an average of 4.2 (SD 4.6), of which 43% (n = 920) included high-risk medications. Having a medication discrepancy was associated with a higher number of home medications (p < 0.0001) comorbidities (p < 0.0001), and source of information (p < 0.04). Conclusion: Obtaining the BPMH by CPhTs on hospital admission frequently identifies medication discrepancies. Further studies are needed to evaluate the association between obtaining the BPMH and clinical outcomes.

Pharmacy student-assisted medication reconciliation: Number and types of medication discrepancies identified by pharmacy students.

Background:Medication reconciliation aims to prevent unintentional medication discrepancies that can result in patient harm at transitions of care. Pharmacist-led medication reconciliation has clear benefits, however workforce limitations can be a barrier to providing this service. Pharmacy students are a potential workforce solution.Objective:To evaluate the number and type of medication discrepancies identified by pharmacy students.Methods:Fourth year pharmacy students completed best possible medication histories and identified discrepancies with prescribed medications for patients admitted to hospital. A retrospective audit was conducted to determine the number and type of medication discrepancies identified by pharmacy students, types of patients and medicines involved in discrepancies.Results:There were 294 patients included in the study. Overall, 72% (n=212/294) had medication discrepancies, the most common type being drug omission. A total of 645 discrepancies were identified, which was a median of three per patient. Patients with discrepancies were older than patients without discrepancies with a median (IQR) age of 74 (65-84) vs 68 (53-77) years (p=0.001). They also took more medicines with a median (IQR) number of 9 (6-3) vs 7 (2-10) medicines per patient (p<0.001). The most common types of medicines involved were those related to the alimentary tract and cardiovascular system.Conclusions:Pharmacy students identified medication discrepancies in over 70% of hospital inpatients, categorised primarily as drug omission. Pharmacy students can provide a beneficial service to the hospital and contribute to improved patient safety by assisting pharmacists with medication reconciliation.

A comparison between medication reconciliation by a pharmacy technician and the use of an online personal health record by patients for identifying medication discrepancies in patients’ drug lists prior to elective admissions

AimMedication discrepancies (MDs), defined as unexplained differences among medication regimens, cause important public health problems with clinical and economic consequences. Medication reconciliation (MR) reduces the risk of MDs, but is time consuming and its success relies on the quality of different information sources. Online personalized health records (PHRs) may overcome these drawbacks. Therefore, the aim of this study is to determine the level of agreement of identified MDs between traditional MR and an online PHR and the correctness of the identified MDs with a PHR. MethodsA prospective cohort study was conducted at the cardiology, neurology, internal medicine and pulmonary department of the Amphia Hospital, the Netherlands. Two weeks prior to a planned admission all patients received an invitation from a PHR to update their medication file derived from the Nationwide Medication Record System (NMRS). At admission MR was performed with all by a pharmacy technician, who created the best possible medication history (BPMH) based on the NMRS data and an interview. MDs were determined as discrepancies between the available information from the NMRS and the input and alterations patients or pharmacy technician made. The number, correctness of patients’ alterations, type and severity of identified MDs were analysed. ResultsOf 488 patients approached, 155 (31.8 %) patients who both used the PHR and had received MR were included. The mean number of MDs identified with MR and PHR was 6.2 (SD 4.3) and 4.7 (SD 3.7), respectively. 82.1 % of the drug information noted by the patient in the PHR was correct compared to the BPMH and 98.6 % had no clinically relevant differences between the lists. ConclusionPatients who used an online PHR can relatively accurately record a list of their medication. Further research is required to explore the level of agreement and the correctness of a PHR in other (larger) hospital(departments).

Assessment of a pharmacy technician medication history program.

To determine the percentage of unintentional prior-to-admission (PTA) medication list discrepancies captured by second-source verification. A prospective, randomized, controlled intervention was conducted on all patients admitted to a large academic medical center with a PTA medication list completed by a pharmacy technician from December 2018 through January 2019. Excluded patients included those admitted as observation status or discharged prior to the time of second-source verification. The following data was collected: patient's medical record number, age, admission date and time, service admitted to, date and time of completed PTA medication list, date and time of second-source verification, type of second-source verification, medication name, dose, route, frequency, formulation, and confidence level of pharmacy technician completing the initial PTA medication list. Second-source verification was conducted on all medications from a patient's PTA medication list after completion by a pharmacy technician. There were a total of 992 medications from the 200 randomly assigned patients with a completed PTA medication list by a pharmacy technician during the study time frame. Of these medications, 116 (11.7%) contained a discrepancy identified by second-source verification. The most common type of discrepancy was omission (67%) followed by dosing, frequency, and formulation. The median time to complete second-source verification was 9 minutes (interquartile range, 5-17 minutes). Second-source verification at the time of hospital admission helps identify medication discrepancies and may improve medication use safety and prescribing pattern and, accordingly, may contribute to reducing medication errors.

The Role of the Nurse in the Management of Medicines During Transitional Care: A Systematic Review.

PurposeTo synthesise knowledge and to explore the role of the nurse in medicines management during transitional care.MethodsAn integrative systematic review was conducted. Electronic databases such as PubMed [including Medline], Web of Knowledge, Scopus, and Cinahl from January 2010 to April 2020 were searched. Original qualitative and quantitative studies written in English that focused on the role of the nurse in medicines management during transitional care, which included movement between short-term, long-term, and community healthcare settings were included.ResultsThe search process led to the retrieval of 10 studies, which were published in English from 2014 to 2020. They focused on the role of the nurse in patients' medicines management during transitional care in various healthcare settings. Given variations in the aims and methods of selected studies, the review findings were presented narratively utilizing three categories developed by the authors. In the first category as ‘medication reconciliation process’ the nurse participated in obtaining medication history, performing medication review, identifying medication discrepancies, joint medication reconciliation and adjustment. The second category as ‘collaboration with other healthcare providers’ highlighted the nurses' role in clarifying medicines' concerns, interdisciplinary communication and consultation, discharge planning and monitoring. In the third category as ‘provision of support to healthcare recipients’, the nurse was responsible for interpersonal communication with patients, education about medicines, and simplification of medication regimens, and symptoms management during transitional care.ConclusionNurses play a crucial role in the safety of medicines management during transitional care. Therefore, they should be empowered and more involved in medicines management initiatives in the healthcare system. Patient safety and avoidance of medication errors during transitional care require that medicines management becomes a multidisciplinary collaboration with effective communication between healthcare providers.

Value of pharmacy services in an outpatient, preoperative, anesthesia clinic

ObjectiveThis pilot study assessed the expansion of pharmacy services to a preoperative, anesthesia clinic. SettingTertiary care academic medical center. Practice descriptionMedication histories were routinely obtained by clinic nurses, and pharmacy services were not available. Practice innovationA prospective, single-center, pilot study enrolled English-speaking patients aged 65 years or older in a preoperative clinic before a scheduled surgery. Patient attributes including health literacy and preparatory activities were measured using verbal and written questionnaires. Home medication lists were obtained by both clinic nurses (routine care) and a pharmacist (research), and the 2 lists were compared to identify medication discrepancies for each patient. Discrepancies were categorized by type and severity. EvaluationThis study evaluated the potential impact of medication histories obtained by pharmacists compared with those obtained by clinic nurses during geriatric preoperative clinic visits. ResultsOf the 44 patients who gave their consent and were included in this pilot study, 25% (n = 11) had limited/marginal written and verbal health literacy, and 20% (n = 9) had limited/marginal numerical health literacy. Of the 38 patients who completed the pharmacist medication history interview, only 21% (n = 8) brought a complete list of their current medications to the preoperative clinic, 95% (n = 36) had at least 1 medication discrepancy, and 61% (n = 23) had at least 1 clinically meaningful discrepancy. Clinically meaningful discrepancies were identified for 8% (35 of 459) of medications and occurred most commonly for blood pressure medications, nonsteroidal anti-inflammatory drugs, and beta blockers. ConclusionIn this study, medication history discrepancies identified by pharmacists suggest that the expansion of pharmacy services into the preoperative clinic is feasible and could potentially prevent meaningful medication errors among geriatric patients being admitted for a scheduled surgery.

Evaluation of the effect of video tutorial training on improving pharmacy students' knowledge and skills about medication reconciliation.

Objectives:This study aimed to describe the effect of using an innovative teaching strategy using a video tutorial on enhancing students’ knowledge about medication reconciliation, and skills in identifying medication discrepancies.Methods:This is a one group pre-post interventional study that was conducted at the School of Pharmacy at Applied Science Private University. Sixty pharmacy students were invited to attend an educational sessions that involve watching a 6-minutes video tutorial. The first two levels of the Kirkpatrick’s Model were used to evaluate the effectiveness of this training tool. Level 1 (Reaction) was assessed using a satisfaction questionnaire, while level 2 (Learning) was assessed using two criteria: 1) student acquired knowledge about medication reconciliation using a questionnaire and a knowledge score out of 13 was calculated for each student, and 2) student acquired skills in identifying medication discrepancies using a virtual case scenario. If the student was able to identify any of the four impeded discrepancies he/she rewarded 1 point for each identified discrepancy, but if they identified any incorrect discrepancy they scored a negative point.Results:Among the 60 students who registered to participate in the study, 49 attended the educational training (response rate 81.6%). The majority of them (n=44, 89.8%) were satisfied with the training process. Before the video tutorial, students showed an overall low knowledge score [4.08/13.0, SD 1.81], and low ability to identify discrepancies [0.72 identified discrepancies out of 4.0, SD 1.1]. Following the video tutorial, the overall knowledge score was improved (p<0.001), and students were able to identify more discrepancies after watching the video (p<0.001).Conclusion:In conclusion, video education has shown itself to be an effective method to educate pharmacy students.. This visualized method can be applied to other areas within pharmacy education. We encourage the integration of videos within the learning process to enhance students’ learning experience and to support the traditional learning provided by the teaching staff.

Intervention fidelity and process outcomes of medication reviews including post-discharge follow-up in older hospitalized patients: Process evaluation of the MedBridge trial.

Drug-related problems (DRPs) are a growing healthcare burden worldwide. In an ongoing cluster-randomized controlled trial in Sweden (MedBridge), comprehensive medication reviews (CMRs) including post-discharge follow-up have been conducted in older hospitalized patients to prevent and solve DRPs. As part of a process evaluation of the MedBridge trial, this study aimed to assess the intervention fidelity and process outcomes of the trial's interventions. For intervention delivery, the percentage of patients that received intervention components was calculated per study group. Process outcomes, measured in about one-third of all intervention patients, included the following: the number of identified medication discrepancies, DRPs and recommendations to solve DRPs, correction rate of discrepancies, and implementation rate of recommendations. The MedBridge trial included 2637 patients (mean age: 81years). The percentage of intervention patients (n=1745) that received the intended intervention components was 94%-98% during admission, and 40%-81% upon and after discharge. The percentage of control patients (n=892) that received at least one unintended intervention component was 15%. On average, 1.1 discrepancies and 2.0 DRPs were identified in 652 intervention patients. The correction and implementation rates were 79% and 73%, respectively. Stop medication was the most frequently implemented recommendation (n=293) and 77% of the patients had at least one corrected discrepancy or implemented recommendation. The intervention fidelity within the MedBridge trial was high for CMRs during hospital stay and lower for intervention components upon and after discharge. The high prevalence of corrected discrepancies and implemented recommendations may explain potential effects of CMRs in the MedBridge trial.

Development and Evaluation of Medication Reconciliation Checklist Tool to Improve Patient Safety

Background: Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication orders. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. The lack of precise and complete information about patient's medicines is the most common contributing factor for the precipitation of patient safety problem around the globe. Objectives: To develop a medication reconciliation checklist tool and evaluate its utility in the assessment of medication discrepancies and contributing factors Methods: A prospective observational study was carried out in the selected departments at a tertiary care hospital. A checklist tool was prepared based on the critical parameters of the reconciliation approach which was used to assess drug discrepancies during care transition and were categorized under Justified and Unjustified medicine discrepancies. Results: A total of 200 cases were reviewed out of which164 cases were identified with the scope of reconciliation and were then followed. The observed discrepancies were categorized as follows; A total of Justified Discrepancies [27] were reported (Therapeutic Equivalence: 0, Clinical Preference: 1, Medical reason: 26), and Unjustified Discrepancies [113] (Omission errors: 31, Modification of dose: 16, Incorrect drugs: 61, Therapeutic Duplication: 4, Drug interactions: 1). Conclusion: The study concluded that medication reconciliation checklist tool was helpful in identifying medication discrepancies. Execution of the medication reconciliation process by a pharmacist can improve drug and patient safety.

Effectiveness of a Medication Reconciliation Simulation in an Introductory Pharmacy Practice Experience Course

Objective. To evaluate the effectiveness of a simulated learning exercise on pharmacy students' ability and perception of their ability to perform medication reconciliation. Methods. Third-year pharmacy students were divided into three groups. Group A attended a 30-minute lecture; group B attended the lecture and participated in a 90-minute workshop; and group C received no training. After groups A and B completed their assigned learning activities, all students participated in a simulated medication reconciliation activity with a standardized patient (SP). Students also completed a pre- and post-intervention survey. Results. One hundred eighty-three students participated. Students in group B scored the highest (74.5%) on the SP activity compared to those in group A (68.9%) and group C (66.1%). Students in group B reported high levels of agreement with all statements describing the lecture, workshop, and SP activity, including that more of these activities should be integrated into the curriculum. Conclusion. A simulated learning exercise significantly improved students' ability to perform medication reconciliation, including obtaining an accurate medication list, correctly identifying medication discrepancies, and proposing appropriate resolutions. Simulated learning exercises should continue to be incorporated in pharmacy education, especially exercises for learning pharmacy practice skills such as medication reconciliation.

Incorporation of Clinical Pharmacy Into a Geriatric Transitional Care Management Program

Transitional care management (TCM) programs have been shown to decrease hospital readmission rates, health-care costs, and medication-related errors and adverse drug events. Pharmacists have been utilized during the medication reconciliation process, during admission, and after hospital discharge to prevent readmission and identify medication discrepancies. There is a lack of data utilizing clinical pharmacists in the geriatric patient population transitional care process after hospital discharge. Less is known about the depth of professional services a pharmacist can perform in the geriatric setting. We analyzed the scope of pharmacist-assisted implementation of transitional care. A total of 365 patients received the clinical pharmacist comprehensive medication review during a 14-month time period. During these reviews, clinical pharmacists identified more than 600 medication discrepancies and offered more than 1000 recommendations to the primary care physician. Additionally, specific medication classes that have been identified to increase the risk of adverse drug events, specifically in older adults, were identified and used to screen for adverse drug events. Using this list, clinical pharmacists were able to identify 39 adverse drug events. The implementation of clinical pharmacists into the TCM program was successful; however, full salary compensation is unlikely with TCM reimbursement alone.

Medication reconciliation in a Swiss hospital: methods, benefits and pitfalls

ObjectivesTo assess the feasibility and main obstacles to the implementation of a medication reconciliation (MR) process in a Swiss hospital and to develop a standardised method which can be used...