Purpose: To design and evaluate the accuracy and efficiency of a medication reconciliation workflow incorporating pharmacist home medication ordering. Methods: Designed and implemented an admission medication reconciliation workflow that expanded the pharmacists’ role to include an initial ordering of home medications. Performed a prospective, pre–post cohort analysis comparing preimplementation accuracy and efficiency data from inpatient medicine and cardiology patients to postimplementation accuracy and efficiency data from our emergency department observation unit. Accuracy for the preimplementation group was defined by the number of unintentional discrepancies identified by pharmacists between the prescriber admission orders and the reconciled home medication lists. Accuracy for the postimplementation group was defined by the prescriber acceptance of pharmacist-ordered home medications. Efficiency was measured by pharmacist time to complete the admission medication reconciliation process. Results: Prescribers accepted 98% of home medication orders placed by pharmacists, which correlated with a significant decrease in the occurrence of home medication orders containing a medication-related problem or discrepancy (46.4% vs 1.3%, P < .0001). The mean pharmacist time spent completing medication reconciliation per admission decreased from 64 to 23 minutes ( P < .0001). Conclusion: Implementation of an admission process that incorporates pharmacist ordering of home medications increased prescribing accuracy and efficiency.

Background: Fixed-dose (FD) regimens of 4-factor prothrombin complex concentrate (4F-PCC) may be effective for the emergent reversal of warfarin; however, the optimal dosing is unknown. Our institution transitioned to a FD regimen of 1000 or 2000 units of 4F-PCC based on indication. Objective: The purpose of this study is to report our experience with FD 4F-PCC compared with a historical weight-based dosing cohort for warfarin reversal. Methods: A retrospective analysis was conducted for 3 groups: central nervous system (CNS) bleeds regardless of international normalized ratio (INR), non-CNS bleeds with an initial INR ≤6, and non-CNS bleeds with an initial INR ≥6.1. The primary outcome of the study was achievement of the target INR. Results: There were 54 patients with a CNS bleed, 153 with a non-CNS bleed and INR ≤6, and 19 with a non-CNS bleed and INR ≥6.1. In the CNS bleeding group, weight-based and FD achieved target INR 79.4% and 70% ( P = 0.52). In the INR ≥6.1 non-CNS bleeding group, weight-based and FD achieved target INR 100% and 70% ( P = 0.21). In the INR ≤6 non-CNS bleeding group, weight-based and FD achieved target INR 86.4% and 57.5% ( P = 0.0002). Conclusion and Relevance: An FD strategy of 2000 units for warfarin reversal for CNS bleeds or INR ≥6.1 was comparable to weight-based dosing. The FD strategy of 1000 units for INR ≤6 achieved target INR less often than weight-based dosing. Application of findings suggest that higher doses may be needed to achieve target INR.