• Joan S Kramer, Paula J Hopkins, James C Rosendale, James C Garrelts, LaDonna S Hale, Tina M Nester, Patty Cochran, Leslie A Eidem, and Robert D Haneke.
• Department of Pharmacy, Wesley Medical Center, Wichita, KS 67214-4976, USA.
• Am J Health Syst Pharm. 2007 Feb 15;64(4):404-22.

PurposeThe feasibility of implementing an electronic system for targeted pharmacist- and nurse-conducted admission and discharge medication reconciliation and its effects on patient safety, cost, and satisfaction among providers and nurses were studied.MethodsThis study was conducted in two phases: a preimplementation phase and a postimplementation phase. In the preimplementation phase, admission medication histories and discharge medication counseling followed standard care processes. During postimplementation, pharmacists and nurses collaborated to electronically complete admission and discharge medication reconciliation documentation. Four reports were developed for medication reconciliation documentation: (1) home medication profile report, (2) home medication reconciliation report, (3) discharge medication reconciliation report, and (4) patient discharge medication report. Patients were contacted after discharge to measure their satisfaction with the medication counseling and medication instructions received. Health care providers completed a survey indicating their satisfaction with the electronic medication reconciliation processes.ResultsA total of 283 patients were included in the study. Patients in the postimplementation group took significantly more prescription and nonprescription medications, and their total number of medications significantly exceeded the number taken by the preimplementation group. Pharmacists completed significantly more dosage changes in the postimplementation phase than in the preimplementation phase. In the preimplementation phase, nurses identified more incomplete medication orders, dosage changes, and allergies than they did in the postimplementation phase. Patients in the postimplementation group reported a higher level of agreement on all survey items regarding adequate discharge medication instructions.ConclusionPatients who had their medications electronically reconciled reported a greater understanding of the medications they were to take after discharge from the hospital, including medication administration instructions and potential adverse effects.

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