Prevalence and severity of discharge medication discrepancies resolved by pharmacists at a veterans affairs teaching hospital

Abstract

Introduction Although reassuring outcome data exist, not all pharmacist discharge efforts have been effective. This may be explained by heterogenous medication reconciliation definitions and processes. At a Veterans Affairs Teaching Hospital, Clinical Pharmacy Specialists (CPS) review the discharge medication reconciliation as part of a multidisciplinary process. The objective of this study is to describe CPS' role in resolving discharge medication reconciliation discrepancies and to evaluate potential patient harm avoided through pharmacist intervention. Methods Patients discharged home on at least one medication between October 21, 2021 and February 16, 2022 were included in this prospective single cohort study at a Veterans Affairs Hospital. Medication discrepancies were recorded. A panel of independent pharmacists categorized the clinical impact of discrepancies based on the potential to cause patient discomfort or clinical deterioration had the discrepancy gone unresolved: unlikely (class I), moderate (class II), or severe (class III). Results A total of 300 discharges were evaluated and 546 discrepancies identified. A majority (n = 202, 67.3%) of discharges had a discrepancy, with an average of 1.8 (SD ± 2.4) discrepancies per discharge. Pharmacists provided education during 84.3% of discharges and spent an average of 21.7 (SD ± 16.7) minutes per discharge. Panelists identified 359 (65.8%) class I, 149 (27.3%) class II, and 38 (7%) class III discrepancies. Omitted medication and incorrect dosing discrepancies conferred highest risk for potential patient harm. An increase in the number of medication changes from admission to discharge was the only variable predictive of discrepancies at discharge. Conclusion Pharmacists play a vital role at hospital discharge by resolving discrepancies and mitigating potential adverse outcomes. Designing discharge systems that prevent omitted medication and incorrect dosing discrepancies may be beneficial as these errors had the largest potential clinical impact; however, this hypothesis was unable to be tested in this study and deserves further research.

Impact of pharmacist‐led discharge medication reconciliation on error and patient harm prevention at a large academic medical center

“…More than half of patient discharges contained at least one error, thus emphasizing the need for PMRD to better optimize patient safety. The results of this study align with previous studies in demonstrating decreases in medication discrepancies and harm reduction from pharmacist involvement in the discharge process 4,10,14 . Similar to Muller et al, our internal medicine teaching services commonly serve an older patient population with multiple comorbidities, who on average have 12 medications upon admission and an average Charlson Comorbidity score of 5.…”

“…However, these studies did not further assess the unintentional discrepancies that were identified, leaving a gap in understanding their potential for patient harm. While Muller et al 10 have evaluated potential patient harm avoided through pharmacist intervention in resolving discharge medication reconciliation discrepancies, there remains a need for further investigation into the financial implications of such interventions.…”