Drug-Therapy Problems, Inconsistencies and Omissions Identified During a Medication Reconciliation and Seamless Care Service

Abstract

Seamless care is the desirable continuity of care delivered to a patient in the healthcare system across the spectrum of caregivers and their environments. Medication Reconciliation is one component of seamless pharmaceutical care. A randomized controlled trial, carried out over nine months with a six-month followup period, investigated the impact of a pharmacist-directed seamless care service. Intervention patients admitted to one of two general medicine units were subjected to a comprehensive seamless care discharge process as they were discharged from a regional, academically affiliated hospital in Moncton, NB. The number, type and potential clinical impact of drug-therapy problems for seamless monitoring (DTPsm) and drug-therapy inconsistencies and omissions (DTIOs) in hospital discharge medications were measured. A total of 253 patients, with 134 patients in the intervention group and 119 in the control group, completed the study. An average of 3.59 DTPsm per intervention patient, with 72.1% of these being scored as having a significant or very significant clinical impact level, were communicated to community pharmacists. Ninety-nine DTIOs were identified and resolved in intervention patients before discharge. A retrospective medical chart review demonstrated that the intervention resolved almost all DTIOs. In conclusion, a pharmacist-directed seamless care service had a significant impact on drug-related clinical outcomes and processes of care.

Hospital pharmacists' perceptions of medication counseling: A focus group study

“…This is critical as poor communication and inadequate transfer of patient information after discharge from hospital can have serious implications to patients' health. [38][39][40][41][42] The pharmacist's role as a transition enabler is well described in the literature. Hospital pharmacists have been key players in providing continuity of care from hospital to community settings communicating with and transferring information to community pharmacists and primary care physicians about patients' medications.…”

An Exploratory Comparison of Medication Lists at Hospital Admission with Administrative Database Records

“…2,8,9 Approximately 60% of errors found in patient charts occur when patients are admitted to, transferred within, or discharged from an institution, 10 and 54% to 74% of patients admitted to the hospital may have at least 1 discrepancy in their admission medication history. [11][12][13][14][15] The most common medication reconciliation errors are omitted medications [11][12][13][14][16][17][18] and omissions or discrepancies in dose information. [12][13][14][16][17][18] Although medication reconciliation has been shown to help decrease medication discrepancies, 10,14,18-21 it is not routinely performed.…”

“…Studies have evaluated the impact of medication histories collected by a variety of health care and allied professionals 12,[14][15][16]18,[24][25][26][27][28] and the use of tools to assist in the process 10,[19][20][21]29,30 and have compared electronic medical records with actual medication use, 17 but to the authors' knowledge, a comparison of a health plan's claims database with patient interview to formulate a list of medication names and doses/strengths has not been investigated.…”

Clinical Pharmacist-Led Medication Reconciliation Initiative at a Newly Established Hospital in Qatar: A Preliminary Report

“…Hospital admission is an interface of care when medication delivery becomes a complex process, and when more than half of medication errors occur [1,2] Discrepancies in medication history taking accounts for approximately 67% -85% of these medication errors, with a potential harm range from 11% to 59% [3][4][5][6][7].…”