Background The Institute for Healthcare Improvement identifies medication reconciliation as the shared responsibility of nurses, pharmacists, and physicians, where each has a defined role. The study aims to assess the clinical impact of pharmacy-led medication reconciliation performed on day one of hospital admission to the internal medicine service. Methods This is a pilot prospective study conducted at two tertiary care teaching hospitals in Lebanon. Student pharmacists who were properly trained and closely supervised, collected the medication history, and pharmacists at the corresponding sites performed the reconciliation process. Interventions related to the unintended discrepancies were relayed to the medical team. The main outcome was the number of unintended discrepancies identified. The time needed for medication history, and the information sources used to complete the Best Possible Medication History were also assessed. The unintended discrepancies were classified by medication class and route of medication administration, by potential severity, and by proximal cause leading to the discrepancy. For the bivariate and multivariable analysis, the dependent variable was the incidence of unintended discrepancies. The “total number of unintended discrepancies” was dichotomized into yes (≥ 1 unintended discrepancy) or no (0 unintended discrepancies). Independent variables tested for their association with the dependent variable consisted of the following: gender, age, creatinine clearance, number of home medications, allergies, previous adverse drug reactions, and number of information sources used to obtain the BPMH. Results were assumed to be significant when p was < 0.05. Results During the study period, 204 patients were included, and 195 unintended discrepancies were identified. The most common discrepancies consisted of medication omission (71.8%), and the most common agents involved were dietary supplements (27.7%). Around 36% of the unintended discrepancies were judged as clinically significant, and only 1% were judged as serious. The most common interventions included the addition of a medication (71.8%) and the adjustment of a dose (12.8%). The number of home medications was significantly associated with the occurrence of unintended discrepancies (ORa = 1.11 (1.03–1.19) p = 0.007). Conclusions Pharmacy-led medication reconciliation upon admission, along with student pharmacist involvement and physician communication can reduce unintended discrepancies and improve medication safety and patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12913-019-4323-7) contains supplementary material, which is available to authorized users.

BackgroundSince 1999, institutions have been highly encouraged to provide special safeguards to reduce the risk of errors associated with potassium chloride (KCl) concentrate for injection such as removing concentrated KCl from floor stock and using commercially available premixed intravenous solutions. In some healthcare institutions, the implementation of these strategies are still lagging behind, and KCl concentrates for injection still pose safety threats to patients.PurposeThe aim of the project was to standardise the ordering and administration of intravenous KCl across a tertiary care hospital, and improve patient safety.Material and methodsThe project consisted of a screening phase (September 2015 to January 2016), an interventional phase consisting of the introduction of KCl premixed bags to the hospital formulary in January 2017 and an evaluation phase post-implementation (February to April 2017).The target population consisted of adult patients prescribed intravenous KCl in the Internal Medicine, Intensive Care and Geriatrics units. The data collection form included patient information and intravenous KCl administration details. The evaluation phase also included focus-group discussions with different medical teams. Descriptive statistics were used to report the different findings.ResultsIn the screening phase, 249 KCl orders were examined. Twenty-three different dilutions of KCl orders were administered. Discrepancies identified included administering higher than the recommended dose for 17.3% of the patients, and administering rates of 15 mEq/hour of intravenous KCl without central catheter and cardiac monitor.In January 2017, KCl concentrates were removed from most clinical wards, and five commercially available premixed intravenous solutions of KCl were introduced to the hospital formulary.In the post-implementation phase, the variations in the dilutions decreased noticeably, but several discrepancies were identified such as the need for different premixed dilutions to serve specific populations such as patients with hypernatraemia and volume restriction, patients with diabetic ketoacidosis and the potential need to keep KCl concentrates for injection in some clinical wards such as dialysis units.ConclusionThe implementation of a standardised protocol for the ordering, preparation and administration of intravenous KCl is essential in reducing the associated patient safety threats.Healthcare institutions are entrusted to provide special safeguards to reduce the risk of errors.References and/or AcknowledgementsInstitute of Safe Medication Practice.No conflict of interest