• Brígida Dias Fernandes, Leonardo Coutinho Ribeiro, Josefa Cristina Pereira Dos Santos, Lorena Rocha Ayres, and Clarice Chemello.
• Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
• Int. J. Clin. Pract. 2021 Oct 1; 75 (10): e14656.

ObjectivesThe study aimed to assess the fidelity of Medication Reconciliation (MR) delivered by the pharmacist at hospital admission and discharge, and the process outcomes.MethodsProspective study conducted in cardiology and cardiovascular surgery unit of a university hospital between September 2019 and January 2020. Independent observers collected data to measure MR fidelity, related to coverage, sources of information used to collect medication history and presence of outstanding and resolved Undocumented Discrepancies (UD). Process outcomes included medication errors and their potential to cause harm, identified by the pharmacist during the formal MR process.ResultsOf the eligible patients, 122 (69.7%) had their medications reconciled in a timely manner at hospital admission and 50 (43.8%) at discharge. The pharmacist consulted 2.76 (±0.8) sources of information to build the medication history, on average. At least one outstanding UD was found in 101 (82.8%) patients at admission and in 41 (82.0%), at discharge. The average number of outstanding UD per patient at admission and discharge was 3.0 (±2.6) and 2.4 (±1.9), respectively. The UD communicated to the physician by the pharmacist during the formal MR process, involved mainly omission errors and were classified as requiring monitoring or potentially necessary intervention. In the univariate analysis, the number of drugs pre-admission and admission, the reason for admission and non-elective readmission in 30 days were associated with the presence of medication errors at admission.ConclusionsThis study found a high number of UD, suggesting flaws in the implementation of MR and highlight the importance of quality measurement.© 2021 John Wiley & Sons Ltd.

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