• Naomi Digiantonio, Jeremy Lund, and Samantha Bastow.
• P T. 2018 Feb 1; 43 (2): 105-110.

ObjectiveTo determine the impact of a pharmacy-led medication reconciliation program at a large community hospital. The magnitude of the benefit of pharmacy-led medication reconciliation was evaluated based on the number of medication-related discrepancies between nursing triage notes and medication histories performed by pharmacy technicians or students. Discrepancies identified by pharmacy personnel medication histories that required pharmacist intervention on physician admission orders were further classified based on expected clinical impact if the error were to be propagated throughout hospitalization.MethodsA retrospective chart review was performed on 200 patients who met the following inclusion criteria: adults admitted from the emergency department from October 1, 2015, to November 17, 2015, with a medication history collected by medication reconciliation personnel (MRP) containing at least three home medications or one high-risk home medication that was reviewed and reconciled by one of the investigators. The primary endpoint was the number of discrepancies between nursing triage notes and pharmacy personnel medication histories. The secondary endpoint was the percentage of pharmacy interventions categorized as "significant," "serious," or "life threatening" on a medication error severity scale. Additional data points included: number and type of clinical interventions; percent of interventions involving high-risk medications; amount of time spent obtaining medication histories and comparing them to admission orders; number and type of sources used; number of home medications; and percent of admitted patients interviewed by the MRP within 24 hours of admission.ResultsIn a population of 200 patients, 1,762 medication history discrepancies were identified. MRP-collected histories identified issues involving 46 patients that required pharmacist intervention for a total of 235 interventions, of which 68% were related to errors categorized as significant, serious, or life threatening.ConclusionUtilization of a pharmacy-led medication reconciliation program decreased the number of significant, serious, and life-threatening medication reconciliation errors upon hospital admission.

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