Background Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk. Objectives To summarize available evidence on medication reconciliation interventions in the hospital setting and identify the most effective practices. Data Sources Medline (1966 through February 2012) and hand search of article bibliographies. Study Selection 26 controlled studies. Data Extraction Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcomes, and results. Data Synthesis Studies were grouped by type of medication reconciliation intervention: pharmacist-related, information technology (IT), or other, and assigned quality ratings utilizing U.S. Preventative Services Task Force criteria. Results 15 of 26 studies reported on pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. 6 studies were classified as good quality. The comparison group for all studies was usual care, with no direct comparisons of different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17/17 studies), potential adverse drug events (5/6 studies), and adverse drug events (2/3 studies), but showed inconsistent reduction in post-discharge healthcare utilization (improvement in 2/8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a ‘high-risk’ patient population. Conclusions There is a paucity of rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes. Available evidence supports medication reconciliation interventions that heavily utilize pharmacy staff and focus on patients at high-risk for adverse events. Higher quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.

Background Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events as well as medication discrepancies or non-adherence with high potential for future harm (potential adverse drug events). Objective The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study sought to determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. Design Randomized controlled trial with concealed allocation and blinded outcome assessors. Setting Two tertiary care academic hospitals. Patients Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. Intervention Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. Measurements The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable adverse drug events, as well as potential adverse drug events. Results Among 851 participants, 432 (50.8%) experienced 1 or more clinically important medication errors; 23% of such errors were judged to be serious, and 2% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential adverse drug events in 253 (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (IRR=0.92; 95% CI, 0.77 to 1.10) or adverse drug events (IRR=1.09; CI, 0.86 to 1.39). Intervention patients tended to have fewer potential adverse drug events (IRR=0.80; CI, 0.61 to 1.04). Limitations The characteristics of the study hospitals and participants may limit generalizability. Conclusions Clinically important medication errors were present among half of patients after hospital discharge and were not significantly reduced by a health-literacy sensitive, pharmacist-delivered intervention.

Background Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. Objectives To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. Design Prospective cohort study Setting One academic medical center and 23 SNFs. Participants We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. Measurements Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. Results The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1808 discharges). 120 readmissions had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. Conclusions A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.

A housestaff-led intervention utilizing education and data feedback with goal setting and peer comparison resulted in safe, significant reductions in daily laboratory testing rates.