Medication-related problems (MRPs) can be a significant patient safety risk, particularly in hospitalized patients. One method used to minimize this safety concern is through medication reconciliation, or the process of documentation of a patient’s outpatient medication list at the time of hospital admission. Medication reconciliation can be performed by any trained health care professional (i.e. nurses, pharmacy technicians, physicians, etc.), however improved patient safety outcomes have been demonstrated when pharmacists perform this process.
Medication-related problems (MRPs) can be a significant patient safety risk, particularly in hospitalized patients. One method used to minimize this safety concern is through medication reconciliation, or the process of documentation of a patient’s outpatient medication list at the time of hospital admission. Medication reconciliation can be performed by any trained healthcare professional (ie, nurses, pharmacy technicians, physicians, etc.), however improved patient safety outcomes have been demonstrated when pharmacists perform this process.
· When compared to other healthcare professionals, pharmacist-performed medication reconciliation identifies more outpatient medications correctly.1
As nurses are tasked with immediate patient care and physicians are tasked with patient diagnosis and treatment, pharmacists are uniquely skilled to perform medication reconciliation in an acute care setting. Pharmacists generally contact at least 2 medication history sources, as 38% of patients are not able to provide a full medication history at the time of interview. Pharmacist-performed medication reconciliation identified medication discrepancies in 1 out of 5 drugs reviewed.
· Pharmacist medication reconciliation decreases 30-day drug-related admissions and ED visits in high-risk older adults.2
As compared to a similar group of patients, patients with pharmacist performed medication reconciliation and discharge counseling had a 16% reduction in hospital visits. Of 54 drug-related readmissions due to suboptimal therapy, 45 patients (83.3%) did not receive pharmacist care during their previous hospitalization. Decreased hospital utilization has the potential to reduce healthcare costs.
· Preventable adverse drug events (ADEs) are decreased following pharmacist-patient counseling at the time of hospital discharge.3
At discharge, 49% of patients receiving a pharmacist medication review were identified to have one or more unexplained discrepancies between their pre-admission and discharge medications. Thirty days following discharge, preventable ADEs occurred at a significantly lower rate in the pharmacist care group (1% v. 11%, P<.01). Common errors resulting in preventable ADEs include discrepancies after discharge, inappropriate medication dosing, and non-adherence.
· Transitions of care services can reduce MRPs identified post-discharge in the outpatient setting.4
Although the frequency of detected MRPs decreased, an average of 1-2 MRPs were detected by pharmacists in an outpatient transitions of care clinic. Important risk factors for MRPs include age and use of medications requiring monitoring (i.e. warfarin, digoxin, etc.). Approximately 63% of these MRPs were related to patient non-adherence to their medication schedule. Although pharmacist interventions in the acute care setting improve patient outcomes, these results stress the importance of continuing medication reconciliation processes in the outpatient setting.
The role of the pharmacist in preventing hospital readmissions is often underestimated, similar to that of a reconnaissance agent. Pharmacists are uniquely trained to perform medication reconciliation and patient discharge counseling. The integration of pharmacists into the medication reconciliation process can improve patient safety outcomes.
Dr Baird is the director of pharmacy practice and product development for the American Society of Consultant Pharmacists (ASCP), where she serves as a resource to members and staff on clinical practice related issues and oversees all activities of ASCP relating to pharmacy practice. ASCP is the only international professional society devoted to optimal medication management and improved health outcomes for all older persons. ASCP's members manage and improve drug therapy and improve the quality of life of geriatric patients and other individuals residing in a variety of environments, including nursing facilities, sub-acute care and assisted living facilities, psychiatric hospitals, hospice programs, and home and community-based care. Dr Baird is an experienced consultant pharmacist and long-term care specialist, who has lectured on safe medication prescribing to geriatric patients to both nursing students and the general public, as well as to pharmacy students.
Dr Callinan received her bachelor of science degree in biochemistry/molecular biology from the Richard Stockton College of New Jersey and her Doctor of Pharmacy degree from the Ernest Mario School of Pharmacy at Rutgers University, where she completed her pharmacy honors thesis on potentially inappropriate medications in older adults. Following completion of her PGY-1 Pharmacy Practice Residency at the VA Maryland Health Care System, Dr Callinan is the 2014-2015 PGY-2 Geriatrics Pharmacy Resident at the University Of Maryland School Of Pharmacy. As part of this program, Dr Callinan works with the American Society of Consultant Pharmacists to promote pharmacists awareness regarding legislative and therapeutic issues pertinent to the elderly.
Disclosure information: The authors report no financial disclosures as related to products discussed in this article.
1. Andreoli L, Alexandra JF, Tesmoingt C, et al. Medication reconciliation: a prospective study in an internal medicine unit. Drugs Aging. 2014;31:387-393.
2. Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older. Arch Intern Med. 2009;169(9):894-900.
3. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-71.
4. Conklin JR, Togami JC, Burnett A, et al. Care transitions service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health-Syst Pharm. 2014;7:802-810.