Pharmacist-led Medication Reconciliation Research Articles

Development and validation of a new drug-focused predictive risk score for postoperative delirium in orthopaedic and trauma surgery patients

BackgroundPostoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients.MethodsOrthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A’s test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established.ResultsPOD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66–75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m2, 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively.ConclusionThe DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.

Medication reconciliation by pharmacists for pre-admission patients improves patient safety

BackgroundMedication errors related to the pre-admission medication history obtained on admission are a major cause of medication error during hospitalization. Medication reconciliation (MR) improves patient safety through the detection of inadvertent medication discrepancies at transitions of care. The aim of this study was to evaluate the effect of MR by pharmacists for patients prior to hospital admission on the incidence of medication errors in the early post-admission period.Patients and methodsPatients admitted to the orthopedic ward for surgery between April 2012 and March 2020 were included. Pharmacist-led MR for pre-admission patients was started on April 1, 2017. The incidence of medication errors related to pre-admission medications that occurred during hospitalization were compared between the pre- and post-initiation of pharmacist-led MR (pre-initiation: April 1, 2012 to March 31, 2015, post-initiation: April 1, 2017 to March 31, 2020).ResultIn the post-initiation group, 94.2% (1245/1321) of patients who were taking medications on admission had a pharmacist-led MR before admission. The proportion of patients whose physicians ordered the prescription of their pre-admission medications at the time before hospitalization to continue from admission was significantly higher in the post-initiation group than in the pre-initiation group (47.4% vs. 1.0%, p < 0.001). The incidence of medication errors related to pre-admission medications during hospitalization was significantly lower in the post-initiation group than in the pre-initiation group (1.83% vs. 0.85%, p = 0.025). Pharmacist-led MR prior to admission was a significant protective factor against incidents related to pre-admission medication (odds ratio (OR), 0.3810; 95% confidence interval (CI); 0.156–0.9320, p = 0.035).ConclusionPharmacist-led MR for patients prior to hospital admission led to a reduction in medication errors related to pre-admission medications during hospitalization. Patient safety during hospitalization can be improved by accurate medication histories provided early by pharmacists.

Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial.

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.

Pharmacist-led medication reconciliation service for patients after discharge from tertiary hospitals to primary care in Singapore: a qualitative study.

Medication discrepancies commonly occur when patients are transferred between care settings. Despite the presence of medication reconciliation services (MRS), medication discrepancies are still prevalent, which has clinical costs and implications. This study aimed to explore the perspectives of various stakeholders on how the MRS can be optimized in Singapore. This is a descriptive qualitative study. Semi-structured interviews with 30 participants from the National Healthcare Group, including family physicians (N = 10), pharmacists (N = 10), patients recently discharged from restructured hospitals (N = 7) and their caregivers (N = 3) were conducted. All transcribed interviews were coded independently by three coders and inductive thematic analysis approach was used. Five core themes were identified. (1) The MRS enhanced healthcare services in various aspects including efficiency and health literacy; (2) There were several challenges in delivering the MRS covering processes, technology and training; (3) Issues with suitable patient selection and follow-up; (4) Barriers to scaling up of MRS that involve various stakeholders, cross-sector integration and environmental restrictions; and finally (5) Role definition of the pharmacist to all the stakeholders. This study identified the role of MRS in enhancing healthcare services and explored the challenges encountered in the provision of MRS from family physicians, pharmacists, patients and their caregivers. These findings supported the need for a shift of MRS towards a more comprehensive medication review model. Future improvement work to the MRS can be conducted based on the findings.

Implementation of pharmacy-led preoperative medication reconciliation in surgical oncology patients

BackgroundPharmacy-led medication history collection and reconciliation have demonstrated decreased medication errors, increased patient safety, and improved cost-savings. However, literature lacks documented efforts to implement such services in the preoperative space, where having accurate medication lists following complex procedures with high postoperative admission rates is critical. ObjectivesThe purpose of this study was to describe the implementation of a telephonic pharmacy student and pharmacist-led preoperative medication reconciliation program. Practice descriptionThe service was piloted using third- and fourth-year pharmacy students to conduct telephonic medication histories for urologic surgical oncology patients. Weekly reports identified eligible patients with scheduled procedures within 2 weeks’ time. Using standardized methods for patient communication and documentation, students authored telephone encounter notes that were reviewed and signed by pharmacist preceptors. Pharmacist preceptors also reconciled home medication lists based on students’ findings. Practice innovationA standardized preoperative medication reconciliation process was developed and implemented utilizing third- and fourth-year pharmacy students. Resulting notes were available for surgical staff on the day of patients’ procedures and upon potential postoperative admission. Evaluation methodsA retrospective chart review was conducted to evaluate successfully documented medication histories collected by pharmacy students within the pharmacy-led preoperative medication reconciliation program. ResultsForty-six medication reconciliation notes were identified between August 2021 and February 2022, and 39 met inclusion criteria. Amongst the 177 medication additions, deletions, and edits, deletions were the most common, and 95% of patients had at least 1 medication discrepancy identified. A total of 33 medication classes were represented by the identified discrepancies, and each encounter took an average of 33 minutes to complete. ConclusionPreoperative medication reconciliation services can be successfully accomplished through a telephonic pharmacy student and pharmacist-led workflow. Accurate medication histories aid in minimizing medication errors and increasing patient safety.

Beyond the Hospital: Redefining the Role of Pharmacists in Transitions of Care

Unjustifiable medication discrepancies or inconsistency are responsible for more than half of medication errors occurring at transitions in care and up to one-third could have the potential to cause harm. Studies have shown that pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. In Singapore, the Hospital-to-Home (H2H) programme in Changi General Hospital (CGH) focuses on providing care to vulnerable patients transitioning from different settings, who are exposed to gaps in care and lapses in quality and safety. The Home Medical Service by Pharmacists was pioneered in CGH and Singapore in October 2020 to enhance provision of pharmacy-related services by certified collaborative prescribing pharmacists in the home setting. The purpose of this quality improvement project is to identify provider and patient characteristics that are predictive of the response towards this new pharmacy service, which in turn influences the referrals to the service.&#x0D; A fishbone diagram was used to analyse and categorise the problems into different factors – pharmacist-, nursing-, physician-, patient-, and process-related. Pharmacist-, nursing- and physician-related factors include poor awareness of the potential value-added roles of pharmacists due to the lack of prescribing experience in the home setting. Patient-related factors include difficulty in establishing the appropriate criteria to identify patients who need pharmacist’s intervention. Process-related factors include potential additional cost to patients.&#x0D; Based on the Model of Improvement, several changes were implemented in two Plan-Do-Study-Act (PDSA) cycles. The first cycle was to perform roadshows to the H2H team comprising of physicians and nurses, to raise awareness of the new pharmacy service and pharmacist's roles (more in-depth medication reconciliation, drug information, and prescribing). After three months, the second cycle was initiated by conducting regular monthly case audits with the H2H team to monitor progress, identify lapses, and receive feedback to further improve processes and explore potential areas that pharmacists can contribute.&#x0D; After implementing PDSA cycle 1, the average number of unique home visits by pharmacists per month increased from 1 visit to 4 visits, and subsequently increased to 8 visits after implementing PDSA cycle 2. A survey was also conducted to determine if the changes implemented were satisfactory to the team. Overall, 80% of responses were satisfied with the Home Medical Service by Pharmacists in managing patients under the H2H programme.&#x0D; This project had enabled us to achieve improvements in several processes which facilitated the refinement of pharmacist’s roles in the H2H programme to complement the team’s current roles and increased awareness of these roles within the team. Lastly, we will continue to further improve other problem areas yet be addressed and together with the H2H team, close the gaps in care for patients undergoing transitions of care.

Appraising the Role of Pharmacists in Medication Reconciliation at Hospital Discharge: A Field-Based Study

Objective: To measure the effect of the pharmacist-led medication reconciliation service before hospital discharge on preventing potential medication errors. Methods: This behavioral interventional study took place in a public teaching hospital in Iraq between December 2022 and January 2023. It included inpatients who were taking four or more medications upon discharge from the internal medicine ward and the cardiac care unit. The researcher provided the patients with a medication reconciliation form and reconciliation form (including medication regimen and pharmacist instructions) before discharging them home. Any discrepancies between the patients’ understanding and the actual medication recommendations prescribed by the physician were identified and solved. Results: Fifty inpatients received a pharmacist-led medication reconciliation review before hospital discharge. Out of 50 patients, 44% had a clear understanding of their medications before the intervention. In contrast, 56% of the patients had at least one potential medication error before the reconciliation, which was addressed by the pharmacist's intervention. Approximately two-thirds (89.4%) of the potential medication errors were clinically significant, and 5.3% of these errors were serious. The most frequent potential error that prevented this was duplication (31.5%) (the patient was about to duplicate the same medication from different manufacturers or different medications from the same pharmacological class). Conclusion: Lack of medication reconciliation can cause significant medication errors, which might be serious and cause harm to patients. This study has the potential to shape policies and practices that prioritize medication safety and optimize patient outcomes during transitions of care.

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system

Objective Performing accurate medication history and reconciliation is recognized to reduce medication discrepancies and errors resulting in improved patient safety. This quality improvement project retrospectively evaluated the impact of a newly implemented pharmacy-led admission medication reconciliation program for several hospitals. Methods In 2020, a pharmacy-led admission medication reconciliation program was implemented in 16 hospitals across a large health system. The program targeted high-risk, complex inpatients admitted through the emergency department and directly to the hospital. Medication history technicians captured the best possible medication list and medication reconciliation pharmacists reviewed the list, collaborating with providers to complete reconciliation, and intervening to optimize drug therapy. A retrospective, pre-post analysis was performed comparing the preimplementation time period of June to November 2019 to the postimplementation time period of June to November 2020. Outcomes evaluated included pharmacy staff productivity, adverse drug events (ADEs), complications, and healthcare professional satisfaction. Results A total of 311,473 patients were admitted to the 16 hospitals during the pre- and postimplementation time periods. During the six-month postimplementation period, nearly 80,000 medication histories and reconciliations were completed, with 39.9% of those histories requiring medication clarification. Both the ADE rate and complication rate decreased significantly after program implementation, 12% decrease ( p &lt; 0.017) and 14% decrease ( p &lt; 0.001), respectively. Healthcare professional survey results from nurse, physician, and pharmacist respondents indicated a statistically significant improvement in satisfaction. Conclusion After implementation of pharmacy-led admission medication reconciliation, patient ADEs and complications decreased during hospitalization, and physician, nurse, and pharmacist satisfaction significantly improved.

Medication Reconciliation Service in Hospitalized Patients with Infectious Diseases During Coronavirus Disease-2019 Pandemic: An Observational Study.

To determine the prevalence and type of medication discrepancies and factors associated with unintentional discrepancies and identify the rate of hospital readmission and emergency service visit within 30 days after discharge among hospitalized patients with infectious diseases and receiving clinical pharmacist-led medication reconciliation during the coronavirus disease-2019 (COVID-19) pandemic. This observational study was conducted in the internal medicine and infectious diseases wards of a tertiary university hospital between July 2020 and February 2021 among hospitalized adult patients with infectious diseases. Medication reconciliation service (including patient counseling) was provided in person or by telephone. The number and type of medication discrepancies detected during the medication reconciliation services, the acceptance rate of pharmacists' recommendation, and factors associated with having at least one unintentional medication discrepancy at admission were evaluated. At follow-up, hospital readmission and emergency service visit within 30 days after discharge were assessed by telephone. Among 146 patients, 84 (57.5%) had at least one unintentional discrepancy at admission. Only three unintentional discrepancies were determined in three patients at hospital discharge. All the pharmacists' recommendations for medication discrepancies were accepted by the physicians. Having COVID-19 [odds ratio (OR): 2.25, 95% confidence interval (CI): 1.15-4.40; p<0.05], being at a high risk for medication error (OR: 2.01, 95% CI: 1.03-3.92; p<0.05), and higher number of medications used at home (OR: 1.41, 95% CI: 1.23-1.61; p<0.001) were associated with having at least one unintentional discrepancy at admission. The rates of 30 day hospital readmission and admission to the emergency medical service were 12.3% and 15.8%, respectively. Medication reconciliation service provided by in-person or by telephone was useful for detecting and solving unintentional medication discrepancies during the COVID-19 pandemic.

Developing an In-House Comprehensive Medication Review Training Program for Clinical Pharmacists in a Finnish Hospital Pharmacy.

Long-term continuing education programs have been a key factor in shifting toward more patient-centered clinical pharmacy services. This narrative review aims to describe the development of Helsinki University Hospital (HUS) Pharmacy's in-house Comprehensive Medication Review Training Program (CMRTP) and how it has impacted clinical pharmacy services in HUS. The CMRTP was developed during the years 2017-2020. The program focuses on developing the special skills and competencies needed in comprehensive medication reviews (CMRs), including interprofessional collaboration and pharmacotherapeutic knowledge. The program consists of two modules: (I) Pharmacist-Led Medication Reconciliation, and (II) CMR. The CMRTP includes teaching sessions, self-learning assignments, medication reconciliations, medication review cases, CMRs, a written final report, and a self-assessment of competence development. The one-year-long program is coordinated by a clinical teacher. The program is continuously developed based on the latest guidelines in evidence-based medicine and international benchmarking in cooperation with the University of Helsinki. With the CMRTP, we have adopted a more patient-centered role for our clinical pharmacists and remarkably expanded the services. This program may be benchmarked in other countries where the local education system does not cover clinical pharmacy competence well enough and in hospitals where the clinical pharmacy services are not yet very patient-oriented.

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.

Effect of a Pharmacist Admission Medication Reconciliation Service at a Children's Hospital.

To evaluate the clinical effect and estimate cost avoidance attributed to a pharmacist-led admission medication reconciliation service at a children's hospital. This was a prospective observational cohort study that measured pharmacist interventions for pediatric patients over a 90-day period. Pharmacists logged all interventions identified during medication reconciliation in real time. Patient demographic data were collected retrospectively. Cost avoidance from prevented adverse drug events (ADEs) was estimated based on previously published literature. Pharmacists completed 283 admission medication reconciliations during the study period. Of those, 69% of medication reconciliations required intervention. Interventions affected care during the hospital admission in 21.9% of patients and 8 medication reconciliations resulted in prevention of a major ADE. This pharmacist-led service resulted in an estimated cost avoidance of $46,746.65 in the 3-month period. Implementation of a pharmacist-led admission medication reconciliation service for pediatric patients improved medication safety and resulted in significant cost avoidance, which justifies investment in these pharmacist resources.

The impact of pharmacist-led medication reconciliation and interprofessional ward rounds on drug-related problems at hospital discharge

BackgroundDuring transitions of care, including hospital discharge, patients are at risk of drug-related problems (DRPs).AimTo investigate the impact of pharmacist-led services, specifically medication reconciliation at admission and/or interprofessional ward rounds on the number of DRPs at discharge.MethodIn this retrospective, single-center cohort study, we analyzed routinely collected data of patients discharged from internal medicine wards of a regional Swiss hospital that filled their discharge prescriptions in the hospital’s community pharmacy between June 2016 and May 2019. Patients receiving one of the two or both pharmacist-led services (Study groups: Best Care = both services; MedRec = medication reconciliation at admission; Ward Round = interprofessional ward round), were compared to patients receiving standard care (Standard Care group). Standard care included medication history taken by a physician and regular ward rounds (physicians and nurses). At discharge, pharmacists reviewed discharge prescriptions filled at the hospital’s community pharmacy and documented all DRPs. Multivariable Poisson regression analyzed the independent effects of medication reconciliation and interprofessional ward rounds as single or combined service on the frequency of DRPs.ResultsOverall, 4545 patients with 6072 hospital stays were included in the analysis (Best Care n = 72 hospital stays, MedRec n = 232, Ward Round n = 1262, and Standard Care n = 4506). In 1352 stays (22.3%) one or more DRPs were detected at hospital discharge. The combination of the two pharmacist-led services was associated with statistically significantly less DRPs compared to standard care (relative risk: 0.33; 95% confidence interval: 0.16, 0.65). Pharmacist-led medication reconciliation alone showed a trend towards fewer DRPs (relative risk: 0.75; 95% confidence interval: 0.54, 1.03).ConclusionOur results support the implementation of pharmacist-led medication reconciliation at admission in combination with interprofessional ward rounds to reduce the number of DRPs at hospital discharge.

Developing a pharmacist-led intervention to provide transitional pharmaceutical care for hospital discharged patients: A collaboration between hospital and community pharmacists

BackgroundPatients who transfer from the hospital back to the community are at risk of experiencing problems related to their medications. Hospital pharmacists (HPs) and community pharmacists (CPs) may play an important role and provide transitional pharmaceutical care in transition of care interventions. ObjectiveTo describe how a pharmacist-led intervention to provide transitional pharmaceutical care for hospital discharged patients was developed, utilizing already existing pharmacist interventions in the hospital and community pharmacy. MethodsA mixed-method approach to intervention development was applied. Existing evidence was identified through a literature review of effective transitional care interventions and existing services in the hospital and community pharmacy. Focus group interviews and a workshop were carried out with HPs and CPs to identify their perceived facilitators and uncertainties in relation to intervention development. The final intervention and the expected outcomes were developed in an expert group workshop. Finally, the hospital part of the intervention was tested in a small-scale feasibility study to assess what type of information the HP would transfer to the CP for follow up. ResultsFive components were identified through the 209 systematic reviews: pharmacist-led medication reconciliation, pharmacist-led medication review, collaboration with general practitioners (GPs), post discharge pharmacist follow up and patient counseling or education. HPs and CPs identified uncertainties related to the relevance of the information sent from the HP to the CP, identification of patients at the community pharmacy and communication. The expected outcomes for the patients receiving the intervention were an experience of increased safety and satisfaction and less use of healthcare resources. The feasibility study led to optimization of language and structure of the pharmacist referrals that were used to transfer information from the HP to the CP. ConclusionA patient centered intervention to provide transitional pharmaceutical care for hospital discharged patients was developed using existing evidence in transition of care, HPs and CPs, an expert group, and a small-scale feasibility study. A full-scale feasibility test of the intervention should be carried out for it to be further refined.

Pharmacist-led medication reconciliation at patient discharge: a tool to reduce healthcare utilization? an observational study in patients 65 years or older

BackgroundOlder patients often experience adverse drug events (ADEs) after discharge that may lead to unplanned readmission. Medication Reconciliation (MR) reduces medication errors that lead to ADEs, but results on healthcare utilization are still controversial. This study aimed to assess the effect of MR at discharge (MRd) provided to patients aged over 65 on their unplanned rehospitalization within 30 days and on both patients’ experience of discharge and their knowledge of their medication.MethodsAn observational multicenter prospective study was conducted in 5 hospitals in Brittany, France.ResultsPatients who received both MR on admission (MRa) and MRd did not have significantly fewer deaths, unplanned rehospitalizations and/or emergency visits related to ADEs (OR = 1.6 [0.7 to 3.6]) or whatever the cause (p = 0.960) 30 days after discharge than patients receiving MRa alone. However, patients receiving both MRa and MRd were more likely to feel that their discharge from the hospital was well organized (p = 0.003) and reported more frequently that their community pharmacist received information about their hospital stay (p = 0.036).ConclusionsThis study found no effect of MRd on healthcare utilization 30 days after discharge in patients over 65, but the process improved patients’ experiences of care continuity. Further studies are needed to better understand this positive impact on their drug care pathway in order to improve patients’ ownership of their drugs, which is still insufficient. Improving both the interview step between pharmacist and patient before discharge and the transmission of information from the hospital to primary care professionals is needed to enhance MR effectiveness.Trial registrationNCT04018781 July 15, 2019.

Pharmacist-led medication reconciliation on admission to an acute psychiatric hospital unit.

Background:Therapy management in patients suffering from mental health disorders is complex and the risks derived from changes or interruptions of treatment should not be ignored. Medication reconciliation in psychiatry may reduce medication errors and promote patient safety during transitions of care.Objective:To identify the influence of complementary information sources in the construction of the best possible medication history, and to ascertain the potential clinical impact of discrepancies identified in a medication reconciliation service.Methods:An observational study was conducted in an acute mental hospital unit, with a further validation in an internal medicine unit. Adult patients taking at least one medicine admitted in the unit were included. Patients/caregivers were interviewed upon admission and the information gathered was compared with hospital medical and shared electronic medical records. Once the best possible medication history was gathered, therapeutic information was reconciled against the prescription on admission to identify discrepancies. Potential clinical impact of medication errors was classified using the International Safety Classification.Results:During the study period, 148 patients were admitted, 50.7% females, mean age 54.6 years (SD=16.3). Collaboration of a caregiver was a needed in 74% of the interviews. In total, 1,147 drugs were considered to obtain patients’ best possible medication history. After reconciliation, 560 clinically sound intentional discrepancies were identified and 359 discrepancies required further clarification from prescribers: 84.12% “drug omission”, 5.57% “drug substitution”, 6.96% “dose change”, and 3.34% “dosage frequency change”. Potential clinical impact of these medication discrepancies was classified as: 95 mild, 100 moderate, and 29 severe medication errors.Conclusion:About 1 in three intentional discrepancies observed in a pharmacists-led medication reconciliation service required further clarification from prescribers, being 80% of them unintentional discrepancies. Results highlight the importance of the caregiver as source of information for the psychiatric patient, the relevance of analyzing shared electronic health records until 6 months before, and the need to use hospital medical records efficiently. Additionally, 29 discrepancies were classified as errors with potentially severe clinical impact. A medication reconciliation service is concluded to be feasible and necessary in a mental health unit.

Pharmacist impact on medication reconciliation of behavioral health patients boarding in the emergency department.

IntroductionThe high demand for psychiatric services has exceeded the capacity of available resources for behavioral health patients, forcing these patients to seek mental health care in the emergency department. Average lengths of stay for behavioral health boarders commonly extend over multiple days and prior-to-admission (PTA) medication administration may be delayed, which could lead to further deterioration and longer inpatient lengths of stay. Addition of a pharmacist-led medication reconciliation process and pharmacist integration into daily emergency department psychiatry rounds may decrease time to initiation of PTA medications and improve outcomes in this population.MethodsThis is a retrospective review of adult patients who required a psychiatric emergency evaluation in a large rural academic medical center emergency department. Objectives were to determine the number and type of medication discrepancies found with pharmacist intervention, and to compare time to initiation of PTA medications with a pharmacist versus a nonpharmacist completing medication reconciliation.ResultsA total of 139 patients were identified, 85 patients in August 2019 (no pharmacist [NP]) and 54 in October 2019 (pharmacist involvement [PI]). Among 484 medications reviewed in the PI group, 298 discrepancies were identified. The most common types of discrepancies were no longer taking (n = 99, 33%) and omission (n = 94, 32%). Time to administration of PTA medications was similar between NP and PI groups (median hours, interquartile range: NP: 10.8, 7.8-16.57; PI: 11.49, 6.16-16; P = .179).DiscussionThis study depicted one of the many values of pharmacists in the hospital setting, especially in the behavioral health patient population where continuation of accurate PTA medications may prevent further clinical deterioration.

30-Day Readmission Reduction in a Skilled Facility Population Through Pharmacist-Driven Medication Reconciliation.

Transitions of care can be difficult to manage and if not performed properly, can lead to increased readmissions and poor outcomes. Transitions are more complex when patients are discharged to skilled nursing facilities. We assessed the impact of pharmacist-led initiatives, including medication reconciliation, on readmission rates between an academic medical center and a local skilled nursing facility (SNF). We conducted a two-phase quality improvement project focusing on pharmacist-led medication reconciliation at different points in the transition process. All-cause 30-day readmission rates, medication reconciliation completion rates, and total pharmacist interventions were compared between the 2 groups. The combined intervention and baseline cohorts resulted in a 29.8% relative reduction (14.5% vs. 20.6%) in readmission rates. Medication reconciliation was completed on 93.8% of SNF admitted patients in the first phase and 97.7% of patients in the second phase. Pharmacist interventions per reconciliation were 2.39 in the first phase compared with 1.82 in the second phase. Pharmacist-led medication reconciliation can contribute to reduction of hospital readmissions from SNFs and is an essential part of the SNF transition process.

Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit.

Objectives: Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). Methods: This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. Results: The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P < .00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P = .01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P = .01). Conclusion: The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected.

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.