Medication Reconciliation In Patients Research Articles

Comparison between proactive and retroactive models of medication reconciliation in patients hospitalized for acute decompensated heart failure.

Most research on the impact of medication reconciliation on patient safety focused on the retroactive model, with limited attention given to the proactive model. This study was conducted to compare the proactive and retroactive models in patients hospitalized for acute decompensated heart failure. This prospective, quasi-experimental study was conducted over six months, from June to November 2022, at the cardiology unit of an academic hospital in Iran. Eligible patients were those hospitalized for acute decompensated heart failure using a minimum of five regular medications before admission. Medication reconciliation was performed in 81 cases using the proactive model and in 81 using the retroactive model. 556 medications were reconciled using the retroactive model, and 581 were reconciled using the proactive model. In the retroactive cases, 341 discrepancies (both intentional and unintentional) were identified, compared to 231 in the proactive cases. The proportion of patients with at least one unintentional discrepancy was significantly lower in the proactive cases than in the retroactive cases (23.80% versus 74.03%). Moreover, the number of unintentional discrepancies was significantly lower in the proactive cases compared to the retroactive cases (22 out of 231 discrepancies versus 150 out of 341 discrepancies). In the retroactive cases, medication omission was the most frequent type of unintentional discrepancy (44.00). About, 42.70% of reconciliation errors detected in the retroactive cases were judged to have the potential to cause moderate to severe harm. While the average time spent obtaining medication history was similar in both models (00:27 [h: min] versus 00:30), the average time needed to complete the entire process was significantly shorter in the proactive model compared to the retroactive model (00:41 min versus 00:51). This study highlighted that the proactive model is a timely and effective method of medication reconciliation, particularly in improving medication safety for high-risk patients.

Initiative to deprescribe high-risk drugs for older adults presenting to the emergency department after falls.

Over 35 million falls occur in older adults annually and are associated with increased emergency department (ED) revisits and 1-year mortality. Despite associations between medications and falls, the prevalence of fall risk-increasing drugs remains high. Our objective was to implement an ED-based medication reconciliation for patients presenting after falls and determine whether an intervention targeting high-risk medications was related to decreased future falls. This was an observational prospective cohort study at a single site in the United States. Adults 65 years and older presenting to the ED after falls had a pharmacist review their medicines. Pharmacists made recommendations to taper, stop, or discuss medications with the primary clinician. At 3, 6, and 12 months, we recorded the number of fall-related return ED visits and determined if recommended medication changes had been implemented. We compared the rate of return visits of patients who had followed the medication change recommendations and those who received recommendations but had no change in their medications using chi-square tests. A total of 577 patients (mean age 81 years, 63.6% female) were enrolled of 1509 potentially eligible patients. High-risk medications were identified in 310 patients (53.7%) who received medication recommendations. High-risk medications were associated with repeat fall-related visits at 12 months (risk difference 8.1% [95% confidence interval 0.97-15.0]). A total of 134 (43%) patients on high-risk medications had evidence of medication modification. At 12 months, there was no statistically significant difference in return fall visits between patients who had modifications to medications compared with those who had not implemented changes (p = 0.551). Our findings identified opportunities for medication optimization in over half of emergency visits for falls and demonstrated that medication counseling in the ED is feasible. However, evaluation of the effect on future falls was limited.

Medication reconciliation for patients after their discharge from intensive care unit to the hospital ward

ObjectivesThe aim of this study was to determine whether the transition of care from the intensive care unit to the ward would pose a high risk for reconciliation errors. The primary outcome of this study was to describe and quantify the discrepancies and reconciliation errors. Secondary outcomes included classification of the reconciliation errors by type of medication error, therapeutic group of the drugs involved and grade of potential severity. MethodsWe conducted a retrospective observational study of reconciliated adult patients discharged from the Intensive Care Unit to the ward. Before a patient was discharged from the intensive care unit, their last intensive care unit's prescriptions were compared with their proposed medication list in the ward. The discrepancies between these were classified as justified discrepancies or reconciliation errors. Reconciliation errors were classified by type of error, potential severity, and therapeutic group. ResultsWe found that 452 patients were reconciliated. At least one discrepancy was detected in 34.29% (155/452), and 18.14% (82/452) had at least one reconciliation errors. The most found error types were a different dose or administration route (31.79% (48/151)) and omission errors (31.79% (48/151)). High alert medication was involved in 19.20% of reconciliation errors (29/151). ConclusionsOur study shows that intensive care unit to non-intensive care unit transitions are high-risk processes for reconciliation error. They frequently occur and occasionally involve high alert medication, and their severity could require additional monitoring or cause temporary harm. Medication reconciliation can reduce reconciliation errors.

Implementation of a compulsory clinical pharmacist-led medication deprescribing intervention in high-risk seniors in the emergency department.

The objective of this study was to assess the impact of an emergency department (ED) deprescribing intervention for geriatric adults. We hypothesized that pharmacist-led medication reconciliation for at-risk aging patients would increase the 60-day case rate of primary care provider (PCP) deprescribing of potentially inappropriate medications (PIMs). This was a retrospective, before-and-after intervention pilot study conducted at an urban Veterans Affairs ED. In November 2020, a protocol utilizing pharmacists to perform medication reconciliations for patients 75 years or older who screened positive using an Identification of Seniors at Risk tool at triage was implemented. Reconciliations focused on identifying PIMs and providing deprescribing recommendations to patients' PCPs. A preintervention group was collected between October 2019 and October 2020, and a postintervention group was collected between February 2021 to February 2022. The primary outcome compared case rates of PIM deprescribing in the preintervention group to the postintervention group. Secondary outcomes include per-medication PIM deprescribing rate, 30-day PCP follow-up visits, 7- and 30-day ED visits, 7- and 30-day hospitalizations, and 60-day mortality. A total of 149 patients were analyzed in each group. Both groups were similar in age and sex, with an average age of 82 years and 98% male. The case rate of PIM deprescribing at 60 days was 11.1% preintervention compared to 57.1% postintervention (p< 0.001). Preintervention, 91% of PIMs remained unchanged at 60 days compared to 49% (p< 0.05) postintervention. Regardless of PIM identification, the 30-day primary care follow-up rate increased postintervention: 31.5% and 55.7% (p< 0.0001), respectively. There was no improvement in 7- or 30-day subsequent ED visits, hospitalization, or mortality. Pharmacist-led medication reconciliation in high-risk geriatric patients was associated with an increase both in the rate of PIM deprescribing and in post-ED primary care engagement.

268 AUDIT: GENERIC PRESCRIBING COMPLIANCE IN AN ACUTE HOSPITAL

Abstract Background Generic prescribing is cost-effective, and evidence suggests that clinical outcomes compared with brand name products are largely equivalent. Hospital guidelines recommend that medications should be prescribed using the approved generic name, not the brand name. There are some exceptions to this. Anecdotal evidence suggests that medication reconciliation for patients on admission to hospital are charted by brand name rather than the generic title. To investigate this we conducted a four-day audit of the prescribing of medications on patients admitted to medical wards in an acute hospital. Methods This audit took place over a four-day period. The Kardex of each patient admitted to the three medical wards was reviewed. Patients admitted under cardiology, haematology and oncology were excluded. All medications including whether they were prescribed using the generic or brand name were collected. Statistical analysis was carried out using Microsoft Excel. Results A total of 33 kardexes were collected. Two hundred and fifty-seven prescribed medications were reviewed. Ninety-five were charted as brand names and 63% (n=162) were prescribed using the generic name. One hundred and eighteen different categories of medications were prescribed. Enoxaparin was prescribed using the brand name ten times and the generic title three times. The antibiotic Piperacillin/tazobactam was prescribed three times using the brand name and one time using the generic title. Of the eight times atorvastatin was prescribed, it was charted using the generic name seven times (88%). Conclusion Almost two-thirds of medications for patients admitted to medical wards are prescribed using generic titles. However, there is room for improvement. Of note, commonly prescribed medications such as enoxaparin and certain antimicrobials were prescribed using the brand name. Opportunities e.g., induction, grand rounds and Non-Consultant Hospital Doctor (NCHD) teaching sessions should be utilised to provide education on the importance of generic prescribing to all NCHDs admitting patients.

Effectiveness of an educational intervention in improving the patient medication reconciliation in the emergency department

This study aimed to evaluate the effectiveness of an educational intervention in improving the patient medication reconciliation process. This was a cross-sectional study that was conducted at St. Jude hospital, California (CA), United States. An educational intervention was provided to the healthcare team working in the emergency department (ED) to explore its effectiveness in improving their patient medication reconciliation practices. A survey was administered to explore the healthcare staff's views on where responsibility lay in their team concerning the fulfilment of appropriate medication reconciliation procedures. Additionally, we identified the barriers facing the completion of appropriate medication reconciliation using open-ended question provided to healthcare staff at the hospital. In the pre-intervention phase, the percentage of patients who received medication reconciliation was statistically significantly higher during the day shift (71.0% compared with 51.3%). In the postintervention phase, the percentage of patients who received medication reconciliation was statistically significantly higher during the night shift (96.7% compared with 75.8%). Overall, the percentage of patients who received medication reconciliation was statistically significantly higher in the postintervention group (81.3%) compared with the pre-intervention group (64.7%) (P<.001). Educational intervention is an effective tool in improving medication reconciliation practices in inpatient settings. The process of medication reconciliation should be conducted based on shared responsibility between healthcare providers and aimed at reducing medication errors and improving patient safety.

Medication Discontinuation in Adults With COPD Discharged From the Hospital: A Population-Based Cohort Study

Background Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation. Research Question What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD? Study Design and Methods A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort. Results Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P Interpretation In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.

Medication reconciliation in orthopedic and neurological patients in a public hospital

Objective: To evaluate the discrepancies found by the clinical pharmacy service during medication reconciliations in patients hospitalized for orthopedics and neurology in a university hospital. Methods: A cross-sectional, descriptive and retrospective study was carried out from January to June 2018 with the patients followed-up by the clinical pharmacy service (orthopedics and neurology). Data was collected through medical charts and pharmacotherapeutic follow-up forms. The differences between the list of medications that the patient was using at home and the prescription from the hospital was classified as a discrepancy (justified or unjustified). Medical acceptance of the pharmaceutical interventions was assessed. The medications involved in the discrepancies were classified according to the ATC classification in its 1st level. Descriptive statistics was performed using the Excel program and Pearson’s chi-square test. Results: Of the 939 medications used by the patients, 673 (71.7%) presented discrepancies and in 371 (55.1%), unjustified discrepancies were found. Of the 507 patients included in the study, 154 (30.4%) presented at least one medication error. In 96.8% of the cases, the pharmaceutical interventions were performed, and acceptability was 30.6%, avoiding 110 errors. Medication omission was the most common type of discrepancy and the medical group most frequently involved was the cardiovascular system. Conclusions: Medication errors in admission to the orthopedics and neurology sectors are frequent, but they can be identified and solved through medication reconciliation, with professional clinical pharmacists able to perform it, collaborating for the safety of the patients.

1842P Impact of medication reconciliation for patients enrolled in oncology early phases clinical trials: A drug-drug interactions retrospective study

Information on drug-drug interactions (DDIs) from clinical trials is non-exhaustive and the risk to include patients with prohibited medications does exist. It was decided to conduct medication reconciliation (MR) by pharmacist during screening period or prior to the enrollment of patients, before starting investigational treatment. The objective of this study is to evaluate the impact of medication reconciliation. All patients enrolled in early phase trial receiving MR by pharmacist between September 2015 and February 2020 were included. To conduct MR, a minimum of 3 sources were used to perform an exhaustive list of medications: patient’s medical record, patient interview and community pharmacy dispensing history, including over-the-counter medications, herbal drugs and food supplements. Protocols and investigator’s brochures provided by the sponsor were consulted to define prohibited or monitored drugs. DDIs of drugs commercialized were checked mainly using FDA or Geneva University Hospital drug interaction lists and interaction analysis websites. In this study, 501 MR were conducted in 469 patients. The median number of drugs per patient was 5 (range 0-17). A total of 1093 drugs (38%) were discovered by pharmacist in 380 patients (76%). Pharmaceutical analysis identified 350 DDIs (12%): 193 monitored drugs and 157 prohibited. More than half of the prohibited medications were herbal drugs, 12% alimentary tract and metabolism drugs, 11% cardiovascular system drugs, 9% nervous system drugs. Most prohibited drugs were stopped and 6% substituted. Among prohibited or monitored drugs, 53% were revealed by MR and unknown by oncologists. MR reduces the risk of DDIs with the investigational drugs, limits protocol deviations by avoiding the co-administration of prohibited medications and helps secure patient care. Sponsors recognized benefits of MR and finance this activity in extra costs. MR takes place in multidisciplinary patient care through the collaboration between oncologists and pharmacists.

Applying the Medications at Transitions and Clinical Handoffs Toolkit in a Rural Primary Care Clinic: Implications for Nursing, Patients, and Caregivers.

Adequate medication reconciliation is related to patients' safety. Rural populations are at increased risk of adverse drug events due to errors in medication reconciliation and often receiving medical care across multiple health care entities and across long distances with separate electronic medical records. This study examined the implementation of Medications at Transitions and Clinical Handoffs Toolkit (MATCH) in a rural primary care clinic and assessed the acceptability and feasibility of implementation. MATCH was developed as a workflow process intervention to improve medication reconciliation. Findings from MATCH implementation indicate that the process improved medication reconciliation workflow. A shared definition of current medications across providers and patients was essential. Empowering patients and caregivers with tools and language to work with providers, particularly nurses, to conduct medication reconciliation during primary care clinic visits is key to improving patient medication reconciliation in rural settings.

Effects of Pharmacist-Conducted Medication Reconciliation at Discharge on 30-Day Readmission Rates of Patients With Chronic Obstructive Pulmonary Disease

Purpose: To analyze effect of pharmacist-conducted medication reconciliation on 30-day readmission rates in chronic obstructive pulmonary disease (COPD) and identify common medication errors among patient with readmissions. Methods: Pharmacists were educated on discharge medication reconciliation for patients with COPD. A retrospective chart review was conducted on patients who underwent pharmacist-conducted discharge medication reconciliation to determine 30-day readmissions. Medication errors analyzed included medication omissions and dose or frequency errors. Previously collected internal research without pharmacist-conducted medication reconciliation served as the control. Results: There were 65 patients in the control group and 50 in the intervention group. About 25% of patients in the control group and 26% of patients in the intervention group had any cause readmissions within 30 days of discharge (P = .87). Both the control and the intervention group had similar COPD-related readmissions of 12.3% and 12.6%, respectively. Medication dose or frequency errors consisted of 68.9% and 46.7% of total errors in the control and the intervention groups, respectively. Long-acting muscarinic antagonist (LAMA) or long-acting beta 2-agonist (LABA) were the most common drug classes to be incorrectly dosed or omitted at discharge. In the intervention group, 30 errors were identified. Due to inability to coordinate discharges, pharmacists intervened on 13 errors, 7 of which were accepted by the prescriber. Conclusion: Pharmacist-conducted medication reconciliation at discharge did not affect 30-day readmission rates of patients with COPD. Confounding factors included a small sample size, passive pharmacist education, and discharge issues. The most common medication errors at discharge were dosing or frequency errors of LABAs or LAMAs.

Effect of pharmacy‐led medication reconciliation in emergency departments: A systematic review and meta‐analysis

Medication reconciliation is recommended to be performed at every transition of medical care to prevent medication errors or adverse drug events. This study investigated the impact of pharmacy-led medication reconciliation on medication discrepancies and potential adverse drug events in the ED to assess the benefits of pharmacy services. The systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The PubMed, Ovid Embase and Cochrane library databases were searched up from inception to 1 July 2018. Studies comparing the effectiveness of the medication reconciliation service performed by pharmacy personnel to usual care (nurses or physicians) in the ED were included. Duplicated studies, non-clinical studies, studies with ineligible comparators or study designs were excluded. Eleven studies were eligible for qualitative analysis, and 8 studies were included in meta-analysis. Pharmacy-led medication reconciliation substantially reduced medication discrepancies in the ED. The most common medication discrepancies included medication omission and incorrect/omitted dose or frequency. Unlike usual care, pharmacy-led medication reconciliation significantly reduced the proportion of patients with medication discrepancies by 68% (response rate 0.32; 95% confidence interval (CI): 0.19-0.53, P<.0001) and the number of medication discrepancy events by 88% (response rate 0.12; 95% CI 0.06-0.26, P<.00001). Intervention decreased the number of discrepancies per patient by 3.08 (mean difference -3.08; 95% CI: -4.76 to -1.39, P=.0003). Subgroup analysis revealed no differences between pharmacists and pharmacy technicians in medication reconciliation performance pertaining to medication discrepancies. The patients with several comorbidities or those administered numerous medications received marked benefits related to reduced medication discrepancies from pharmacy-led medication reconciliation. Moreover, a randomized controlled trial revealed decreased risk of potential adverse drug events by pharmacy-led medication reconciliation in patients receiving care in the ED. Pharmacy-led medication reconciliation significantly decreased the number of medication discrepancies. However, only one study investigated potential adverse drug events in patients receiving care in the ED. Therefore, further studies investigating the direct clinical impact of decreased medication discrepancies are required.

User-Centered Design of a Patient Medication Reconciliation Module in an Integrated Personal Health Record.

With the adoption of Personal Health Records (PHRs) integrated with Electronic Health Records (EHRs) and the increase of accessibility to data, institutions have the possibility of exchanging medical information with their patients. Involving the patient reported data has the potential to improve the quality of care and safety and create a feedback loop between patients and health professionals. The objective of this study is to describe a user-centered design of a module for medication list with reconciliation functionalities managed by the patients themselves, and connected to their EHR for supervision and medical validation. We conducted 42 interviews (31 patients and 11 general practitioners). From the interviews, we performed qualitative analysis and extracted the main findings from comments in both groups. Correctitude rate was 57 to 100%, and satisfaction of use (SUS) maximum was 96% and 92%. These findings may be relevant to patients, health care providers, and policymakers.

Medication Error Patients Admitted to Medical Ward in Primary Hospital, Ethiopia: Prospective Observational Study

Medication error (ME) is broadly defined as any error in the prescribing, dispensing, or administration of a drug. ME is the single most preventable cause of patient harm. An infinite number of medication error exist because of the rapidly expanding array of drug products available, the growing number of diseases being recognized & diagnosed, and the growing number of patients entering the health care system. To evaluate the most frequently encountered drug class undergo medication errors, to identify sources of medication error and evaluate predictors of medication errors among patients admitted to medical ward in primary hospital, northwest Ethiopia. Prospective observational study was conducted from April 1/2018-October/2019G.C. All adult patients who met inclusion criteria were included in the study. Patient medication adherence was evaluated using morisky adherence scale. Independent predictors of outcome identified and strength of association between dependent and independent variables determined by using binary logistic regression analysis and statistical significance was considered at p<0.05. Two hundred sixty patients were included in the analysis. Among these, majority of them were encountered medication errors. Anti-infective drugs were mostly prescribed as well as medication error encountered. Unnecessary drug therapy is the most common error. Proportion of patients with medication error is lower among patients who are on 1-3 drugs as compared to those patient who are on more than five drugs (p=0.025). Patients who stayed less than one week less likely encountered medication errors as compared to those stay more than a week (p=0.024). Since medication availability is significant determinant for medication error, hospital should try to avail medication and prevent medication errors. Clinical pharmacists should involve in multidisciplinary team and continuous patient medication reconciliation should be integral part of patient medical management.

589. Assessment of an Antiretroviral Therapy Policy in Patients with Human Immunodeficiency Virus at a Large Academic Medical Center

BackgroundAccurate medication reconciliation upon hospital admission is crucial for patients with human immunodeficiency virus (HIV) to ensure continuation of appropriate antiretroviral therapy (ART). An ART policy was implemented at our institution which restricted ART ordering to infectious diseases physicians to increase appropriate ART prescribing following admission. The purpose of this study was to evaluate the effectiveness of the HIV medication restriction policy on the appropriateness of ART re-ordering upon admission.MethodsThis was a single-center, retrospective chart review conducted from July 2014 to June 2017 as a pre–post intervention study. The pre-intervention group included adult patients with HIV who received one or more doses of ART prior to implementation of the HIV medication restriction policy. The post-intervention group included adult patients with HIV who received one or more doses of ART after implementation of the policy. Exclusion criteria included patients who received ART for hepatitis B infection or prophylaxis, HIV post-exposure prophylaxis, or patients receiving a first dose of ART for occupational exposure. Home ART medication regimen and inpatient ART medication regimen were evaluated. The primary endpoint was to compare the rate of appropriate medication reconciliations completed before and after implementation of the HIV medication restriction policy. The secondary endpoint was to compare the time to restart of ART following admission.ResultsA total of 115 patients were included in this study. Appropriate medication reconciliation increased from 76% to 100% after implementation of the policy (P = 0.014). However, the mean time to re-initiation of ART increased from 7.9 hours to 14.5 hours after implementation of the policy (P = 0.01). ART regimens were restarted within 24 hours of admission in 96.7% of the pre-HIV policy group vs. 84% in the post-HIV policy group (P = 0.02).ConclusionThe mean time to re-initiation of ART increased after implementation of the HIV policy. However, restriction of ART ordering to infectious diseases physicians significantly increased the rate of appropriate medication reconciliation for patients with HIV. In light of these results, a procedure will be established to ensure the timely re-initiation of ART.Disclosures All authors: No reported disclosures.

Off-Label Prescribing and Polypharmacy: Minimizing the Risks

Off-label prescribing and polypharmacy are commonplace in today's health care environment. Patients are treated with multiple medications obtained through multiple providers, and all too frequently, there is no collaboration amongst professionals. Nurses can address these issues by educating themselves and their patients regarding medication indications and uses, side effects, risks, and benefits. By exploring a patient's medication reconciliation, including over-the-counter agents, and identifying the U.S. Food and Drug Administration-approved indications, as well as potential off-label uses and overlapping side effects of the medications prescribed, nurses can facilitate collaboration among prescribers to reduce polypharmacy, minimize medication side effects, and alleviate drug-drug interactions, while improving patient outcomes and quality of life. [Journal of Psychosocial Nursing and Mental Health Services, 55(2), 17-22.].

Medication reconciliation for patients undergoing spinal surgery.

In recent years, a marked increase of spinal operations prompted a debate on quality issues. Besides obvious factors, such as the surgical technique, medication safety has been identified as one of the major risk factors for patients undergoing anesthesia and surgery. While the issue has already been addressed by hospital pharmacist and anesthesiologists, the prescription of correct medication remains within the surgeons' responsibility. We, therefore, investigated medication-related errors in spinal instrumentation patients and applied current medication reconciliation strategies. We performed a data survey on all patients undergoing spinal instrumentation in 2011. Risk factors for medication safety were identified and prioritized. Specific counter-measures were introduced in 2012 and evaluated in 2013. 147 patients were included in the 2011 and 162 in the 2013 survey. As top five risk factors we identified the preoperative stopping of medication, recording the medication history, prescription process of postoperative analgetics and anticoagulants and the medication list at discharge. Specific counter-measures included standardization of preparations, doses and the prescription process and improving access to this information (online and via a smartphone application). In elective patients, recording the medication histories was delegated to a hospital pharmacist and informative flyers and posters were used to integrate the patients themselves into the process. Counter-measures directed against the first four risk factors resulted in a significant reduction of medication errors. The last risk factor was targeted by instructing the responsible staff only, which proved to be a rather ineffective measure. Medication safety could be significantly improved by implementation of counter-measures specific to the identified risk factors.

Medication reconciliation in patients hospitalized in a cardiology unit.

ObjectivesTo compare drugs prescribed on hospital admission with the list of drugs taken prior to admission for adult patients admitted to a cardiology unit and to identify the role of a pharmacist in identifying and resolving medication discrepancies.MethodThis study was conducted in a 300 bed university hospital in Brazil. Clinical pharmacists taking medication histories and reconciling medications prescribed on admission with a list of drugs used prior to admission. Discrepancies were classified as justified (e.g., based on the pharmacotherapeutic guidelines of the hospital studied) or unintentional. Treatments were reviewed within 48 hours following hospitalization. Unintentional discrepancies were further classified according to the categorization of medication error severity. Pharmacists verbally contacted the prescriber to recommend actions to resolve the discrepancies.ResultsA total of 181 discrepancies were found in 50 patients (86%). Of these discrepancies, 149 (82.3%) were justified changes to the patient's home medication regimen; however, 32 (17.7%) discrepancies found in 24 patients were unintentional. Pharmacists made 31 interventions and 23 (74.2%) were accepted. Among unintentional discrepancies, the most common was a different medication dose on admission (42%). Of the unintentional discrepancies 13 (40.6%) were classified as error without harm, 11 (34.4%) were classified as error without harm but which could affect the patient and require monitoring, 3 (9.4%) as errors could have resulted in harm and 5 (15.6%) were classified as circumstances or events that have the capacity to cause harm.ConclusionThe results revealed a high number of unintentional discrepancies and the pharmacist can play an important role by intervening and correcting medication errors at a hospital cardiology unit.

Transitions in Care: Medication Reconciliation in the Community Pharmacy Setting After Discharge

Objective: To assess the feasibility of a workflow process in which pharmacists in an independent community pharmacy group conduct medication reconciliation for patients undergoing transitions in care.&#x0D; Methods: Three workflow changes were made to improve the medication reconciliation process in a group of three independent community pharmacies. Analysis of the process included workflow steps performed by pharmacy staff, pharmacist barriers encountered during the medication reconciliation process, number of medication discrepancies identified, and pharmacist comfort level while performing each medication reconciliation service.&#x0D; Key Findings: Sixty patient medication reconciliation services met the inclusion criteria for the study. Pharmacists were involved in all steps associated with the medication reconciliation workflow, and were the sole performer in four of the steps: verifying discharge medications with the pharmacy medication profile, resolving discrepancies, contacting the prescriber, and providing patient counseling. Pharmacists were least involved in entering medications into the pharmacy management system, performing that workflow step 13% of the time. The most common barriers were the absence of a discharge medication list (24%) and patient notpresent during consultation (11%). A total of 231 medication discrepancies were identified, with an average of 3.85 medication discrepancies per discharge. Pharmacists' comfort level performing medication reconciliation improved through the 13 weeks of the study.&#x0D; Conclusions: These findings suggest that medication reconciliation for patients discharged from hospitals and long term care facilities can be successfully performed in an independent community pharmacy setting. Because many medication discrepancies were identified during this transition of care, it is highly valuable for community pharmacists to perform medication reconciliation services.&#x0D; &#x0D; Type: Original Research

The importance of medication reconciliation for patients and practitioners

The importance of medication reconciliation for patients and practitioners