• Deirdre M Holland.
• Health Service Executive, Dublin Mid-Leinster, Naas General Hospital, Naas, Co. Kildare, Republic of Ireland, deirdre.holland@hse.ie.
• Int J Clin Pharm. 2015 Apr 1; 37 (2): 310-9.

BackgroundMedication reconciliation is a basic principle of good medicines management. With the establishment of the National Acute Medicines Programme in Ireland, medication reconciliation has been mandated for all patients at all transitions of care. The clinical pharmacist is widely credited as the healthcare professional that plays the most critical role in the provision of medication reconciliation services.ObjectivesTo determine the feasibility of the clinical pharmacist working with the hospital doctor, in a collaborative fashion, to improve the completeness and accuracy of discharge prescriptions through the provision of a pharmacist led discharge medication reconciliation service.Setting243-bed acute teaching hospital of Trinity College Dublin, Ireland.MethodCross-sectional observational study of discharge prescriptions identified using non-probability consecutive sampling. Discharge medication reconciliation was provided by the clinical pharmacist. Non-reconciliations were communicated verbally to the doctor, and documented in the patient's medical notes as appropriate. The pharmacist and/or doctor resolved the discrepancies according to predetermined guidelines.Main Outcome MeasuresNumber and type of discharge medication non-reconciliations, and acceptance of interventions made by the clinical pharmacist in their resolution. Number of discharge medication non-reconciliations requiring specific input of the hospital doctor.ResultsIn total, the discharge prescriptions of 224 patients, involving 2,245 medications were included in the study. Prescription non-reconciliation was identified for 62.5 % (n = 140) of prescriptions and 15.8 % (n = 355) of medications, while communication non-reconciliation was identified for 92 % (n = 206) of prescriptions and 45.8 % (n = 1,029) of medications. Omission of preadmission medications (76.6 %, n = 272) and new medication non-reconciliations (58.5 %, n = 602) were the most common type. Prescription non-reconciliations were fully resolved on 55.7 % (n = 78) of prescriptions prior to discharge; 67.9 % (n = 53) by the doctor, 26.9 % (n = 21) by the clinical pharmacist, and 5.2 % (n = 4) by the joint input of doctor and pharmacist. All communication non-reconciliations were resolved prior to discharge; 97.1 % (n = 200) by the pharmacist, and 2.9 % (n = 6) by both doctor and pharmacist.ConclusionThis study demonstrates how interdisciplinary collaboration, between the clinical pharmacist and hospital doctor, can improve the completeness and accuracy of discharge prescriptions through the provision of a pharmacist led discharge medication reconciliation service at an Irish teaching hospital.

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