Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting

Abstract

Objective:To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting.Methods:This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment.Results:During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04).Conclusion:Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved.

Development of a Student-Led Ambulatory Medication Reconciliation Program at an Academic Institution

“…As previously discussed, effective and accurate completion of medication reconciliation is one of the Joint Commission's National Patient Safety Goals (NPSG 03.06.01), and as such, sound processes have been implemented in the inpatient setting. 1,2,5,[9][10][11][12][13] The current literature regarding this topic focuses on accuracy of the completed medication reconciliation as well as who conducted the process. Formal medication reconciliation in the ambulatory care setting is currently lacking with fewer studies describing the implementation of such processes.…”

<p>Hospital-Wide Medication Reconciliation Program: Error Identification, Cost-Effectiveness, and Detecting High-Risk Individuals on Admission</p>

“…We relied heavily on previous literature that has demonstrated dedicated MHTs can appropriately identify errors when adequately trained. 2 , 4 , 5 , 15 We did not attempt to identify that an adverse medication error would have occurred had a BPMH not been completed. We followed Society of Hospital Medicine best practice recommendations that the BPMH be completed by someone other than the admitting provider to maximize identification of unintentional errors.…”

“…Due to the increased opportunity for error and the risk associated with these errors, there is a growing pool of literature on the topic of medication history programs. [2][3][4][5][22][23][24][25][26] Many of these studies focus on emergency department-based pilot programs or individual departments within a hospital; however, there is little data evaluating these programs in a hospital-wide or institution-wide setting. There is also little data on what specific factors place an individual patient at higher risk for medication error upon admission to a hospital.…”

“…Some hospitals have begun to employ specialist pharmacy technicians to collect the best possible medication history (BPMH). Previous studies have indicated a positive impact on accuracy with error reductions upward of 88% 2 – 5 , 22 , 25 , 26 but few studies have evaluated hospital-wide coverage from a fully developed program. It has been estimated that 39% of prescription medication history errors have the potential to cause moderate to severe discomfort or deterioration in a patient’s condition.…”

Clinical Outcomes of Student Pharmacist–Driven Medication Histories at an Academic Medical Center

“…The benefit which students offer to the medication history and reconciliation process has been evaluated in at least 7 published reports. [13][14][15][16][17][18][19] Each of these reports evaluated the number of discrepancies identified between medication histories obtained by nonpharmacy staff and one obtained by the student pharmacist. Each study demonstrated a significant impact on the accuracy of the documented home medication list and provided a rationale for extending the pharmacy departments' ability to be involved in medication history taking and medication reconciliation by involving students.…”