Clinical pharmacist-led program on medication reconciliation implementation at hospital admission: experience of a single university hospital in Croatia

Abstract

AimTo evaluate the clinical pharmacist-led medication reconciliation process in clinical practice by quantifying and analyzing unintentional medication discrepancies at hospital admission.MethodsAn observational prospective study was conducted at the Clinical Department of Internal Medicine, University Hospital Dubrava, during a 1-year period (October 2014 – September 2015) as a part of the implementation of Safe Clinical Practice, Medication Reconciliation of the European Network for Patient Safety and Quality of Care Joint Action (PASQ JA) project. Patients older than 18 years taking at least one regular prescription medication were eligible for inclusion. Discrepancies between pharmacists' Best Possible Medication History (BPMH) and physicians' admission orders were detected and communicated directly to the physicians to clarify whether the observed changes in therapy were intentional or unintentional. All discrepancies were discussed by an expert panel and classified according to their potential to cause harm.ResultsIn 411 patients included in the study, 1200 medication discrepancies were identified, with 202 (16.8%) being unintentional. One or more unintentional medication discrepancy was found in 148 (35%) patients. The most frequent type of unintentional medication discrepancy was drug omission (63.9%) followed by an incorrect dose (24.2%). More than half (59.9%) of the identified unintentional medication discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration in the patient.ConclusionAround 60% of medication errors were assessed as having the potential to threaten the patient safety. Clinical pharmacist-led medication reconciliation was shown to be an important tool in detecting medication discrepancies and preventing adverse patient outcomes. This standardized medication reconciliation process may be widely applicable to other health care organizations and clinical settings.

Medication discrepancies in hospitalized cancer patients: Do we need medication reconciliation?

“…not serious, and unlikely to cause patient discomfort. Unlike other studies conducted in the same research institution, JUH in Jordan 3 and in Croatia 21 which revealed that most of the discrepancies were serious, 67.4% and 60%, respectively. This probably is due to more care being practiced with cancer patients.…”

“…Serious consequences accompany undocumented intentional discrepancies too, where the physician has intentionally made the choice to change the medication but did not clearly document it. The frequency of undocumented intentional discrepancies was as high as 33.7%, with even higher frequencies seen in other studies, 65% from a study conducted in the same institution for internal medicine patients in general 3 and 83.2% from a study conducted in Europe, 21 which means that other team workers are probably unaware of any changes taken, leaving the patient more susceptible to other forms of discrepancies, and therefore continuing the cycle of discrepancies. Doctors and residents in JUH work under a lot of pressure and that being due to the large number of patients assigned for each doctor, which in turn increases the probability of committing a discrepancy.…”

Impact of a pharmacy technician-centered medication reconciliation program on medication discrepancies and implementation of recommendations

“…This is similar to the data previously reported for medication reconciliation in the internal medicine population, and is also a reflection of the patient comorbidities and the most commonly reconciled drug classes. 14 Classifying the pharmacist’s recommendations and the percentage of recommendations implemented by the prescriber during medication reconciliation is not well documented in literature. In this study only urgent recommendations were verbally communicated to prescribers and all other recommendations were documented in the EHR.…”

Identifying Unintentional Medication Discrepancies at Admission among Elderly Inpatients in Vietnam

“…The most frequent type of unintentional medication discrepancy identi ed was medication omissions (75.9%), followed by medication change (21.8%). Similarly, previous studies had also reported medication omission as the most common type of discrepancy (15,16,27,28). Potential reasons for the unintentional omission of medications among patients at hospital admission or discharge include incomplete information regarding the patients' preadmission medication lists, issues surrounding the anamnesis of patients during interviews, and the complexity of patients' medication regimens.…”