A simple tool to improve medication reconciliation at the emergency department

Approaches to medication history taking in different hospital settings: A scoping review

PURPOSE

A comprehensive medication history can contribute to safe therapy. Many approaches aiming to improve medication history taking require significant human resources. To design an efficient process that delivers high-quality medication histories, the individual requirements and resources of a given setting need to be considered. We aimed to provide an overview of existing approaches to medication history taking and their performance in different settings to potentially support the selection of an appropriate procedure.

METHODS

We searched 3 literature databases (PubMed/MEDLINE, CINAHL, PsycINFO) for publications on approaches to medication history taking and analyzed them with regard to their key components as well as the setting, patient population, assessed outcomes, and efficacy.

RESULTS

In total, 65 publications were included and analyzed. The majority of the reported approaches relied on involvement of dedicated staff (n = 43), followed by process-oriented interventions (eg, checklists; n = 15) and information technology (IT)-guided interventions (n = 11). A mean (SD) of 6 (2.9) outcomes were described in each study. Medication discrepancies were reported in 89% of all studies, yet about 75 different descriptions of this outcome were used, making it difficult to compare study results. Only 11 studies applied a sample size calculation and statistical tests. Of those, 10 reported a positive effect of their respective intervention on the quality of medication histories.

CONCLUSION

Most approaches focused on pharmacy staff, which are associated with considerable cost and resources. Therefore, IT-based approaches and patient engagement should be investigated as cost-effective alternatives and tested for superiority in the same setting. Reporting guidelines and standardized methodology are needed to improve the comparability of such studies.

Therapy and guideline adherence at a multidisciplinary hypertension clinic: A prospective, observational study

BACKGROUND

Hypertension is highly prevalent and remains one of the most frequent and preventable causes of cardiovascular morbidity and mortality. Yet, suboptimal blood pressure control is common. Hypertension clinics might play an important role in improving target attainment, by targeting drug therapy adherence, improving guideline compliance and by involving pharmacists.

OBJECTIVES

We aimed to characterize patient drug therapy adherence, prescriber guideline compliance and pharmacist interventions at the hypertension clinic.

METHODS

A prospective observational study was performed at the hypertension clinic of a large, academic hospital. Adult Dutch-speaking patients were eligible for inclusion. Following data were collected: patient demographics, medication use, patient adherence to prescribed antihypertensive drug therapies according to the BAASIS tool and prescriber compliance to the 2018 European Society of Cardiology (ESC) hypertension guidelines.

RESULTS

A cohort of 108 patients was included with 51.9% male and aged 65 (IQR: 52-75) years. In total, 104 patients took at least 1 antihypertensive drug and 46 patients (44.2%) were classified as non-adherent with regard to their antihypertensive treatment; 82 patients (78.8%) had suboptimal blood pressure control. Compliance with the ESC guidelines was 66.3% prior to the consultation at the clinic and significantly increased to 77.9% thereafter (p = 0.0015). The clinical pharmacist performed a medication review for 27 patients with a total of 44 recommendations and an acceptance rate of 59.1%.

CONCLUSION

A visit to the multidisciplinary hypertension clinic improved prescriber guideline compliance and the use of single pill combinations. Involvement of a clinical pharmacist could be beneficial to further improve patient drug therapy adherence and guideline compliance.

Medication Discussions With Patients With Cardiovascular Disease in the Emergency Department: An Opportunity for Emergency Nurses to Engage Patients to Support Medication Reconciliation

INTRODUCTION

This study aimed to investigate the level of patient involvement in medication reconciliation processes and factors associated with that involvement in patients with cardiovascular disease presenting to the emergency department.

METHODS

An observational and cross-sectional design was used. Patients with cardiovascular disease presenting to the adult emergency department of an academic medical center completed a structured survey inclusive of patient demographics and measures related to the study concepts. Data abstracted from the electronic health record included the patient's medical history and emergency department visit data. Our multivariable model adjusted for age, gender, education, difficulty paying bills, health status, numeracy, health literacy, and medication knowledge and evaluated patient involvement in medication discussions as an outcome.

RESULTS

Participants' (N = 93) median age was 59 years (interquartile range 51-67), 80.6% were white, 96.8% were not Hispanic, and 49.5% were married or living with a partner. Approximately 41% reported being employed and 36.9% reported an annual household income of <$25,000. Almost half (n = 44, 47.3%) reported difficulty paying monthly bills. Patients reported moderate medication knowledge (median 3.8, interquartile range 3.4-4.2) and perceived involvement in their care (41.8 [SD = 9.1]). After controlling for patient characteristics, only difficulty paying monthly bills (b = 0.36, P = .005) and medication knowledge (b = 0.30, P = .009) were associated with involvement in medication discussions.

DISCUSSION

Some patients presenting to the emergency department demonstrated moderate medication knowledge and involvement in medication discussions, but more work is needed to engage patients.

Interception of chronic medication discrepancies by the clinical pharmacist in the emergency department

The emergency department (ED) is a high-risk setting for the occurrence of medication discrepancies (MDs) due to inconsistencies between real and documented chronic medication therapies. A clinical pharmacist (CP) improves medication safety by performing a structured medication reconciliation on ED admission. The main objective was to identify the frequency and type of MDs in the chronic medication therapy by comparing the medication displayed in the home medication module of the electronic medical record and in the genereal practitioner's (GP) referral letter with the best possible medication history by performing a structured medication reconciliation on ED admission. This prospective, monocentric, interventional study was carried out in the ED of a tertiary care university hospital in Brussels, Belgium. Inclusion criteria were patients of at least 65 years, polypharmacy, ED admission between 8 a.m. and 4 p.m. on weekdays, hospitalization and signed informed consent. During 24 days, a CP performed a structured medication reconciliation in order to obtain the best possible medication history and registered all MDs. The CP compared the best possible medication history with the home medication module and the GP's referral letter and registered the different types of MDs. Eighty-three patients were included. The median number of medications in the home medication module and the best possible medication history was significantly different {7.0 [interquartile range (IQR), 5.0-11.0] vs. 8.0 (IQR, 6.0-11.0)/patient; P < 0.0001} with a median of 5.0 (IQR, 3.0-8.0) MDs per patient. Main MDs were omission (38.8%), addition (18.4%) and a deviant administration time (15.2%). Only 22.9% of patients ( N = 19) had a GP's referral letter containing their chronic medication therapy. The median number of medications in the GP's referral letter and the best possible medication history were significantly different [6.0 (IQR, 4.0-9.0) vs. 8.0 (IQR, 7.0-11.0)/patient; P < 0.0001] with a median of 6.0 (IQR, 5.0-11.0) MDs per patient. Main MDs were omissions (39.9%), deviant frequencies (35.3%) and doses (16.7%). A CP, integrated in a multidisciplinary ED team, enhances medication safety by intercepting MDs on ED admission. Few patients possess a GP's referral letter containing their chronic medication therapy and when they do, the accuracy and completeness are poor.

The effect of a trAnSitional Pharmacist Intervention in geRiatric inpatients on hospital visits after dischargE (ASPIRE): Protocol for a randomized controlled trial

BACKGROUND

Unplanned rehospitalizations occur frequently in older patients. Drug-related problems constitute a major and largely preventable cause with inappropriate prescribing being a substantial culprit. Solutions are needed to reduce this risk by targeting pharmacotherapy both during and after hospital stay. Therefore, we aim to perform a randomized controlled trial in geriatric inpatients to investigate the impact of a multifaceted clinical pharmacy intervention on health-related outcomes.

METHODS/DESIGN

The study concerns a monocenter, non-blinded, randomized controlled trial that will take place at the acute geriatric wards of a large academic hospital. Patients being in a palliative stage with active therapy withdrawal or patients discharged to another ward within the same hospital or another hospital are excluded. In total, 828 patients will be randomized (1:1) to the usual care or intervention group. The multifaceted clinical pharmacy intervention comprises medication reconciliation at admission and discharge, medication review, patient/caregiver education, intensified communication with primary care providers and post-discharge follow-up, which also includes a telepharmacology service. The primary endpoint is defined as the time to an all-cause, unplanned hospital revisit within six months after discharge. Other health-related outcomes such as drug-related readmissions, quality of life and number of potentially inappropriate medications will be analyzed as secondary endpoints. Patient inclusion started in February 2021.

DISCUSSION

This study will provide useful insights regarding the impact of clinical pharmacy interventions on geriatric wards with the goal to optimize health-related outcomes such as hospital revisits.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04617340.

Reducing medication errors for adults in hospital settings

BACKGROUND

Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death.

OBJECTIVES

To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775).

AUTHORS' CONCLUSIONS

Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

The Reliability of Anamnestic Data in the Management of Clostridium Tetani Infection in Elderly

Background: Tetanus infection remains a significant complication of wounds. Because most tetanus treatment guidelines rely on anamnestic data collected directly from patients, the congruence between anamnesis and laboratory evidence must be verified, especially in the elderly population.

Aim: Assess, in both the geriatric population (>65) and the non-geriatric one, the reliability of anamnestic data for managing patients with tetanus-risk wounds, identified categories of populations most exposed to non-vaccination coverage, and assessed the agreement of the Tetanos Quick Stick (TQS) results with the therapy performed (administration of tetanus vaccine or immunoglobulin).

Methods: In this retrospective single-center observational study, patients were asked their immunization status against tetanus vaccination. The decision to administer a vaccine or immunoglobulin was therefore clinical and based on anamnestic criteria. The TQS test was then given to patients who were unaware of their immunity status. Patients who thought they knew it but were not sure were given the TQS test to determine whether the anamnestic collection was supported by the test. The TQS test results were compared with the anamnestic data.

Results: Most patients, geriatric and not geriatric, did not know their immune status. Among those who reported knowing their immune status, there was no agreement between the vaccine coverage declared by patients and the TQS test results (p < 0.001), mainly in geriatric patients but also in the control group. Elderly and women had significantly lower positive TQS test results (p < 0.001). There was a statistically significant discrepancy (p < 0.001) between the therapy based on anamnestic data and the TQS test results.

Conclusion: The reliability of anamnestic data for the management of patients with tetanus-risk wounds is low and decreases with age, becoming minimal in geriatric patients. Elderly and women are less likely to have an effective vaccination status against tetanus.

Factors associated with the number of clinical pharmacy recommendations: findings from an observational study in geriatric inpatients

Objectives: Drug-related problems are prevalent in older inpatients and can be reduced by providing clinical pharmacy (CP) services. Details concerning implementation in clinical practice are frequently lacking. The aim was to describe the output of one such CP program and to identify factors associated with CP recommendations.Methods: A CP program was installed at three acute geriatric wards in a teaching hospital. A convenience sample was collected, consisting of inpatients who received a CP consultation at discharge. Medical conditions, patient demographics, and drug use were evaluated retrospectively. Number and type of the CP recommendations were determined. A Poisson regression analysis was performed to determine factors associated with the number of CP recommendations.Results: A cohort of 524 patients, aged 85 (interquartile range (IQR): 82-89) years was included. On admission, 10.31 (standard deviation: 4.49) drugs were taken. Three (IQR: 2-4) CP recommendations were provided per patient, of which 70.2% targeted drug discontinuation. A model was derived, containing the following factors: number of drugs on admission (incidence rate ratio (IRR): 1.063; 95% confidence interval (CI): 1.052-1.074), number of previous contacts with the geriatric department (IRR: 0.869; 95%CI: 0.816-0.926), presence of left-ventricular dysfunction (IRR: 1.179, 95% CI: 1.023-1.360), the number of new drugs (IRR: 1.046; 95% CI: 1.021-1.071) and use of colecalciferol (IRR: 1.22; 95% CI: 1.088-1.367).Conclusions: Five factors were associated with the number of CP recommendations at discharge. This could allow for further patient stratification to increase the efficiency of the CP program.

Agreement in Medications Reported in Medical and Dental Electronic Health Records

INTRODUCTION

The historical separation between medicine and dentistry has resulted in the creation of separate health records, which have the potential to negatively impact patient care and safety. Of particular importance, errors or omissions in medication lists in separate electronic health records (EHRs) may lead to medical errors and serious adverse outcomes.

OBJECTIVE

This study aimed to compare medication lists reported in the EHRs of active patients treated by both the University of Michigan School of Dentistry and Michigan Medicine to determine if differences exist.

METHODS

In this cohort study, EHRs of a population of 159,733 patients that the University of Michigan medical and dental clinics share in common were investigated for agreement in the reporting of 16 medications. After exclusion of minors and patients not seen in the last 5 y, records of 27,277 patients were examined.

RESULTS

The maximum percentage of agreement in medications reported in both records was 52% for levothyroxine, and the minimum was 7% for sildenafil. The medical record had a significantly higher number of unique medications than the dental record, suggesting higher underreporting in the dental setting.

CONCLUSION

The lack of agreement in the report of medications with serious dental and medical implications argues in favor of unification of records and use of available technology to increase accurate medication reporting.

KNOWLEDGE TRANSFER STATEMENT

The results demonstrate a lack of agreement between medications reported in medical and dental records, which can have serious implications to patients' health. A unified health record, employing available technology to increase accurate medication reporting, would mitigate this problem.

Advanced Medication Reconciliation: A Systematic Review of the Impact on Medication Errors and Adverse Drug Events Associated with Transitions of Care

OBJECTIVE

The goal of this study was to conduct a systematic review on the impact of in-hospital electronic/enhanced medication reconciliation compared to basic medication reconciliation on medication errors, discrepancies, and adverse drug events (ADEs).

METHODS

The study team searched for peer-reviewed English-language articles in EMBASE, OVID, and Scopus databases up to October 2019. Included were randomized controlled trials (RCTs), pre-post, or interrupted time series designs with medication errors, discrepancies, or ADEs as an outcome, and medication reconciliation applied at hospital discharge. Basic medication reconciliation was defined as using a paper-based format, electronic medication reconciliation as using an electronic format, and enhanced medication reconciliation as incorporating additional interventions to reduce medication errors.

RESULTS

Ten studies (three RCTs, one retrospective cohort study, two interrupted time series studies, three pre-post studies, and one longitudinal study) were identified, with six and four studies comparing basic medication reconciliation to electronic and enhanced medication reconciliation, respectively. The overall risk of bias of the included studies was low (three), unclear (two), moderate (three), and serious/high (two). In general, studies demonstrated that electronic medication reconciliation reduced the odds of a medication discrepancy or ADE and may reduce the mean number of medication discrepancies. Enhanced medication reconciliation was more equivocal, with some studies showing improvement; however, risk of bias was generally significant.

CONCLUSION

Electronic medication reconciliation tends to reduce the risk of ADE; however, these conclusions were limited due to a lack of consistency in study settings, interventions, and outcome definitions. Future studies with more rigorous designs and standardized outcome definitions would provide clarity on this topic.

Developing an Integrated Electronic Medication Reconciliation Platform and Evaluating its Effects on Preventing Potential Duplicated Medications and Reducing 30-Day Medication-Related Hospital Revisits for Inpatients

The aims were to develop an integrated electronic medication reconciliation (ieMR) platform, evaluate its effects on preventing potential duplicated medications, analyze the distribution of the potential duplicated medications by the Anatomical Therapeutic and Chemical (ATC) code for all inpatients, and determine the rate of 30-day medication-related hospital revisits for a geriatric unit. The study was conducted in a tertiary medical center in Taiwan and involved a retrospective quasi pre-intervention (July 1-November 30, 2015) and post-intervention (October 1-December 31, 2016) study design. A multidisciplinary team developed the ieMR platform covering the process from admission to discharge. The ieMR platform included six modules of an enhanced computer physician order entry system (eCPOE), Pharmaceutical-care, Holistic Care, Bedside Display, Personalized Best Possible Medication Discharge Plan, and Pharmaceutical Care Registration System. The ieMR platform prevented the number of potential duplicated medications from pre (25,196 medications, 2.3%) to post (23,413 medications, 3.8%) phases (OR 1.71, 95% CI, 1.68-1.74; p < .001). The most common potential duplicated medications classified by the ATC codes were cardiovascular system (28.4%), alimentary tract and metabolism (26.4%), and nervous system (14.9%), and by chemical substances were sennoside (12.5%), amlodipine (7.5%), and alprazolam (7.4%). The rate of medication-related 30-day hospital revisits for the geriatric unit was significantly decreased in post-intervention compared with that in pre-intervention (OR = 0.12; 95% CI, 0.03-0.53; p < .01). This study indicated that the ieMR platform significantly prevented the number of potential duplicated medications for inpatients and reduced the rate of 30-day medication-related hospital revisits for the patients on the geriatric unit.

Strategies for improving physician documentation in the emergency department: a systematic review

BACKGROUND

Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown.

METHODS

We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation.

RESULTS

Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results.

CONCLUSIONS

Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.

Medication review versus usual care to improve drug therapies in older inpatients not admitted to geriatric wards: a quasi-experimental study (RASP-IGCT)

Background

Interdisciplinary geriatric consultation teams (IGCT) are regularly requested to provide comprehensive geriatric assessments in older inpatients. Our primary aim was to evaluate whether medication reviews increased the number of IGCT-provided drug-related recommendations. Secondary aims were to reduce the number of potentially inappropriate medications (PIMs), and to identify the acceptance rate of and determinants for the number of recommendations.

Methods

A before-after study was performed in older inpatients not admitted to acute geriatric wards. The before cohort received usual care (UC); the after cohort was subjected to the intervention (I), consisting of a systematic medication review, based on but not limited to the RASP (Rationalization of Home Medication by an Adjusted STOPP in Older Patients) list. The primary outcome measure was the number of IGCT-provided drug-related recommendations. Age, sex, Charlson Comorbidity Index, creatinine clearance and serum creatinine were ascertained upon enrolment. Following variables were determined on admission and at discharge: number of drugs and number as well as type of RASP-identified PIMs. Acceptance by ward-based physicians was also determined. Poisson regression was performed to identify determinants for the primary outcome measure.

Results

Fifty-nine participants were enrolled (n_UC = 29; n_I = 30). The intervention increased the number of drug-related recommendations from a median of 0 (IQR: 0–1) to 8 (IQR: 6.75–10) (p < 0.001). The median number of accepted recommendations differed significantly as well (UC vs. I: 0.0 (0.0–0.5) vs. 3.0 (0.0–5.3); p < 0.001). In the intervention cohort, patients were discharged with fewer drugs compared to admission (UC vs. I: 108.5%, IQR: 100.0–135.8% vs. 92%, IQR: 80.5–103.5%; p = 0.002). More RASP PIMs were discontinued in the intervention cohort, with a mean difference of 1.49 RASP PIMs (95% confidence interval (CI): 0.70, 2.23; p < 0.001). Regression analysis identified two determinants: allocation to the intervention cohort with an incidence rate ratio (IRR) of 14.1 (95% CI: 8.30, 23.8) and the number of preadmission drugs with an IRR of 1.06 (95% CI: 1.03, 1.09).

Conclusions

A structured medication review as part of usual IGCT care may contribute to an increased detection of drug-related problems and help to further reduce polypharmacy in older inpatients, not admitted to acute geriatric care wards.

Trial registration

NCT02165618, retrospectively registered June 17, 2014.

The Introduction of a Full Medication Review Process in a Local Hospital: Successes and Barriers of a Pilot Project in the Geriatric Ward

For the majority of Belgian hospitals, a pharmacist-led full medication review process is not standard care and, therefore, challenging to introduce. With this study, we aimed to evaluate the successes and barriers of the implementation of a pharmacist-led full medication review process in the geriatric ward at a local Belgian hospital. To this end, we carried out an interventional study, performing a full medication review on older patients (≥70 years) with polypharmacy (≥5 drugs) who had an unplanned admission to the geriatric ward. The process consisted of 3 steps: (1) medication reconciliation upon admission; (2) medication review using an explicit reviewing tool (STOPP/START criteria or GheOP³S tool), followed by a discussion between the pharmacist and the geriatrician; and (3) medication reconciliation upon discharge. Ethical approval was obtained from the Ethical Commission of the Ghent University Hospital. Outcomes included objective data on the interventions (e.g., number of drug discrepancies; number of potentially inappropriate prescriptions (PIP)); as well as subjective experiences (e.g., satisfaction with service; opinion on inter-professional communication). There was a special focus on communication aspects within the introduction of this process. In total, 52 patients were included in the study, taking a median of 10 drugs (IQR 8-12). Upon admission, 122 drug discrepancies were detected. During medication review, 254 PIPs were detected and discussed, leading to an improvement in the appropriateness of medication use. The satisfaction of community pharmacists concerning additional communication and the satisfaction of the patients after counselling at discharge were positive. However, several barriers were encountered, such as the time-consuming process to gather necessary information from different sources, the non-continuity of the service due to the lack of trained personnel or the lack of safe, electronic platforms to share information. The communicative and non-communicative successes and hurdles encountered during this project need to be addressed in order to improve the full medication review process and to strengthen the role of the clinical pharmacist.

Combined Use of the Rationalization of Home Medication by an Adjusted STOPP in Older Patients (RASP) List and a Pharmacist-Led Medication Review in Very Old Inpatients: Impact on Quality of Prescribing and Clinical Outcome

BACKGROUND

Polypharmacy and potentially inappropriate drugs have been associated with negative outcomes in older adults which might be reduced by pharmacist interventions.

OBJECTIVES

Our objective was to evaluate the effect of a pharmacist intervention, consisting of the application of the Rationalization of home medication by an Adjusted STOPP in older Patients (RASP) list and a pharmacist-led medication review on polypharmacy, the quality of prescribing, and clinical outcome in geriatric inpatients.

METHODS

A monocentric, prospective controlled trial was undertaken at the geriatric wards of a large university hospital. Pharmacists applied the RASP list to the drugs reconciled on admission and additionally performed an expert-based medication review, upon which recommendations were provided to the treating physicians. The primary outcome was the composite endpoint of drug discontinuation and dose reduction of drugs taken on admission. Secondary outcomes included RASP-identified potentially inappropriate medications (PIMs), the number of Emergency Department (ED) visits and quality of life (QOL) registered up to 3 months after discharge.

RESULTS

On average, patients (n = 172) took 10 drugs on admission and were 84.5 years (standard deviation 4.8) of age. More drugs were discontinued or reduced in dose in the intervention group {control vs.intervention:median (interquartile range [IQR]) 3 (2-5) vs. 5 (3-7); p < 0.001}. More PIMs were discontinued in the intervention group, leading to less PIM at discharge [control vs.intervention:median (IQR) 2 (1-3) vs. 0.5 (0-1); p < 0.001]. No signal of harm was seen, and a significant improvement of QOL and less ED visits without hospitalization were observed.

CONCLUSIONS

The combined intervention safely reduced drug use in very old inpatients and outperformed usual geriatric care. An increased QOL was seen, as well as a trend towards less ED visits. ClinicalTrials.gov Identifier: NCT01513265.

Clinical relevance of pharmacist intervention in an emergency department

OBJECTIVES

To evaluate the clinical relevance of pharmacist intervention on patient care in emergencies, to determine the severity of detected errors. Second, to analyse the most frequent types of interventions and type of drugs involved and to evaluate the clinical pharmacist's activity.

METHODS

A 6-month observational prospective study of pharmacist intervention in the Emergency Department (ED) at a 400-bed hospital in Spain was performed to record interventions carried out by the clinical pharmacists. We determined whether the intervention occurred in the process of medication reconciliation or another activity, and whether the drug involved belonged to the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. To evaluate the severity of the errors detected and clinical relevance of the pharmacist intervention, a modified assessment scale of Overhage and Lukes was used. Relationship between clinical relevance of pharmacist intervention and the severity of medication errors was assessed using ORs and Spearman's correlation coefficient.

RESULTS

During the observation period, pharmacists reviewed the pharmacotherapy history and medication orders of 2984 patients. A total of 991 interventions were recorded in 557 patients; 67.2% of the errors were detected during medication reconciliation. Medication errors were considered severe in 57.2% of cases and 64.9% of pharmacist intervention were considered relevant. About 10.9% of the drugs involved are in the High-Alert Medications ISMP list. The severity of the medication error and the clinical significance of the pharmacist intervention were correlated (Spearman's ρ=0.728/p<0.001).

CONCLUSIONS

In this single centre study, the clinical pharmacists identified and intervened on a high number of severe medication errors. This suggests that emergency services will benefit from pharmacist-provided drug therapy services.

Medication reconciliation as a medication safety initiative in Ethiopia: a study protocol

INTRODUCTION

Medication related adverse events are common, particularly during transitions of care, and have a significant impact on patient outcomes and healthcare costs. Medication reconciliation (MedRec) is an important initiative to achieve the Quality Use of Medicines, and has been adopted as a standard practice in many developed countries. However, the impact of this strategy is rarely described in Ethiopia. The aims of this study are to explore patient safety culture, and to develop, implement and evaluate a theory informed MedRec intervention, with the aim of minimising the incidence of medication errors during hospital admission.

METHODS AND ANALYSES

The study will be conducted in a resource limited setting. There are three phases to this project. The first phase is a mixed methods study of healthcare professionals' perspectives of patient safety culture and patients' experiences of medication related adverse events. In this phase, the Hospital Survey on Patient Safety Culture will be used along with semi-structured indepth interviews to investigate patient safety culture and experiences of medication related adverse events. The second phase will use a semi-structured interview guide, designed according to the 12 domains of the Theoretical Domains Framework, to explore the barriers and facilitators to medication safety activities delivered by hospital pharmacists. The third phase will be a single centre, before and after study, that will evaluate the impact of pharmacist conducted admission MedRec in an emergency department (ED). The main outcome measure is the incidence and potential clinical severity of medication errors. We will then analyse the differences in the incidence and severity of medication errors before and after initiation of an ED pharmacy service.

Impact of electronic medication reconciliation interventions on medication discrepancies at hospital transitions: a systematic review and meta-analysis

Background

Medication reconciliation has been identified as an important intervention to minimize the incidence of unintentional medication discrepancies at transitions in care. However, there is a lack of evidence for the impact of information technology on the rate and incidence of medication discrepancies identified during care transitions. This systematic review was thus, aimed to evaluate the impact of electronic medication reconciliation interventions on the occurrence of medication discrepancies at hospital transitions.

Methods

Systematic literature searches were performed in MEDLINE, PubMed, CINHAL, and EMBASE from inception to November, 2015. We included published studies in English that evaluated the effect of information technology on the incidence and rate of medication discrepancies compared with usual care. Cochrane’s tools were used for assessment of the quality of included studies. We performed meta-analyses using random-effects models.

Results

Ten studies met our inclusion criteria; of which only one was a randomized controlled trial. Interventions were carried out at various hospital transitions (admission, 5; discharge, 2 and multiple transitions, 3 studies). Meta-analysis showed a significant reduction of 45 % in the proportion of medications with unintentional discrepancies after the use of electronic medication reconciliation (RR 0.55; 95 % CI 0.51 to 0.58). However, there was no significant reduction in either the proportion of patients with medication discrepancies or the mean number of discrepancies per patient. Drug omissions were the most common types of unintended discrepancies, and with an electronic tool a significant but heterogeneously distributed reduction of omission errors over the total number of medications reconciled have been observed (RR 0.20; 95 % CI 0.06 to 0.66). The clinical impact of unintended discrepancies was evaluated in five studies, and there was no potentially fatal error identified and most errors were minor in severity.

Conclusion

Medication reconciliation supported by an electronic tool was able to minimize the incidence of medications with unintended discrepancy, mainly drug omissions. But, this did not consistently reduce other process outcomes, although there was a lack of rigorous design to conform these results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0353-9) contains supplementary material, which is available to authorized users.

Hospital Pharmacy in Belgium: From Moving Boxes to Providing Optimal Therapy

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Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis

OBJECTIVES

Pharmacists play a role in providing medication reconciliation. However, data on effectiveness on patients' clinical outcomes appear inconclusive. Thus, the aim of this study was to systematically investigate the effect of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO from inception to December 2014. Included studies were all published studies in English that compared the effectiveness of pharmacist-led medication reconciliation interventions to usual care, aimed at improving medication reconciliation programmes. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity.

RESULTS

17 studies involving 21,342 adult patients were included. Eight studies were randomised controlled trials (RCTs). Most studies targeted multiple transitions and compared comprehensive medication reconciliation programmes including telephone follow-up/home visit, patient counselling or both, during the first 30 days of follow-up. The pooled relative risks showed a more substantial reduction of 67%, 28% and 19% in adverse drug event-related hospital revisits (RR 0.33; 95% CI 0.20 to 0.53), emergency department (ED) visits (RR 0.72; 95% CI 0.57 to 0.92) and hospital readmissions (RR 0.81; 95% CI 0.70 to 0.95) in the intervention group than in the usual care group, respectively. The pooled data on mortality (RR 1.05; 95% CI 0.95 to 1.16) and composite readmission and/or ED visit (RR 0.95; 95% CI 0.90 to 1.00) did not differ among the groups. There was significant heterogeneity in the results related to readmissions and ED visits, however. Subgroup analyses based on study design and outcome timing did not show statistically significant results.

CONCLUSION

Pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. This review supports the implementation of pharmacist-led medication reconciliation programmes that include some component aimed at improving medication safety.

Clinical pharmacist review: a randomised controlled trial

OBJECTIVES

To determine if medication review by a clinical pharmacist of older patients in the ED impacted on admission to hospital and other outcomes.

METHODS

A stratified, randomised controlled study comparing the intervention to current practice. A tertiary referral ED in New South Wales, Australia. Older people (>70 years) living at home who initially reported taking greater than five medications. Medication review by an experienced hospital pharmacist within the ED. Rate of admission, rate of readmission, length of stay and admission to an aged care facility at 4 months post presentation, and rate of general practitioner acceptance of pharmacist recommendations.

RESULTS

The odds of admission decreased for those receiving the intervention (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.53, 0.87; P = 0.002). There was no evidence that the intervention affected hospital length of stay for admitted patients (0.09 days change, 95% CI -0.08, 0.25; P = 0.31), the rate of re-presentation (0.08% change, 95% CI -0.12, 0.28; P = 0.44) or admission to an aged care facility. The odds of admission to an aged care facility increased with the Identification of Seniors at Risk score. General practitioners adopted 49% of pharmacists' recommendations.

CONCLUSIONS

The presence of an experienced pharmacist in the ED reduced hospital admissions. Further study is required to determine longer term impacts of General Medical Practitioner acceptance of pharmacists' recommendations.

Barriers and facilitators of medication reconciliation processes for recently discharged patients from community pharmacists' perspectives

BACKGROUND

Community pharmacists play a vital part in reconciling medications for patients transitioning from hospital to community care, yet their roles have not been fully examined in the extant literature.

OBJECTIVES

The objectives of this study were to: 1) examine the barriers and facilitators community pharmacists face when reconciling medications for recently discharged patients; and 2) identify pharmacists' preferred content and modes of information transfer regarding updated medication information for recently discharged patients.

METHODS

Community pharmacists were purposively and conveniently sampled from the Wisconsin (U.S. state) pharmacist-based research network, Pharmacy Practice Enhancement and Action Research Link (PEARL Rx). Community pharmacists were interviewed face-to-face, and transcriptions from audio recordings were analyzed using directed content analysis. The Theory of Planned Behavior (TPB) guided the development of questions for the semi-structured interviews.

RESULTS

Interviewed community pharmacists (N = 10) described the medication reconciliation process to be difficult and time-consuming for recently discharged patients. In the context of the TPB, more barriers than facilitators of reconciling medications were revealed. Themes were categorized as organizational and individual-level themes. Major organizational-level factors affecting the medication reconciliation process included: pharmacy resources, discharge communication, and hospital resources. Major individual-level factors affecting the medication reconciliation process included: pharmacists' perceived responsibility, relationships, patient perception of pharmacist, and patient characteristics. Interviewed pharmacists consistently responded that several pieces of information items would be helpful when reconciling medications for recently discharged patients, including the hospital medication discharge list and stop-orders for discontinued medications.

CONCLUSIONS

The TPB was useful for identifying barriers and facilitators of medication reconciliation for recently discharged patients from community pharmacists' perspectives. The elucidation of these specific facilitators and barriers suggest promising avenues for future research interventions to improve exchange of medication information between the community pharmacy, hospitals, and patients.

Adverse drug event nonrecognition in emergency departments: an exploratory study on factors related to patients and drugs

BACKGROUND

Many adverse drug events (ADEs) are not identified by emergency physicians. Research has been done to study risk factors for ADEs and help emergency physicians diagnose ADEs. However, no research has specifically examined the causes underlying a lack of attribution of ADEs to medications in emergency department (ED) patients.

OBJECTIVE

We conducted an exploratory study in a medical ED to search for the factors associated with ADE nonrecognition that are related to ED patients and ADEs.

METHODS

We conducted an observational study in the medical ED of a French tertiary care hospital between January and December 2009. The study focused on all ADEs, whether or not they were related to the patient's chief complaint. ADEs were identified by an expert physician and pharmacist based on National Electronic Injury Surveillance System criteria. An ADE was considered "attributed" if any evidence of ADE suspicion, ADE diagnosis, or ADE management was documented on ED charts. Factors associated with ADE nonrecognition were identified using multiple logistic regression analysis.

RESULTS

Of the 465 included patients, 90 experienced an ADE at ED visit (19.4%; 95% confidence interval [CI] 15.9%-23.2%). Emergency physicians correctly recognized 36 of these cases (40.0%; 95% CI 29.8%-50.9%). On multivariate analysis, ADE nonrecognition was significantly associated with the following variables: nonrelation between the ADE and the patient's chief complaint; daily prescription of four drugs or more; and hospitalization ADE severity category.

CONCLUSIONS

Our results emphasize the importance of searching for ADEs in patients with daily polypharmacy or whose chief complaint does not seem to be drug related.

[Medication reconciliation on hospital admission in patients with multiple chronic diseases using a standardised methodology]

OBJECTIVES

To determine the incidence of medication errors when admitting patients with multiple chronic conditions to hospital, using a standard method.

MATERIAL AND METHOD

A prospective, observational study was conducted on patients with multiple chronic conditions admitted to a tertiary hospital. The medication reconciliation was performed using the standard method considered the most suitable for these patients by an expert panel, following the Delphi methodology. The main information source used for this was the computerised clinical notes, both in primary care and in the hospital, recurring to a clinical interview if necessary. Discrepancies justified by the clinician, as well as reconciliation errors were recorded. The type of error and the pharmacological group involved were analysed and the seriousness of each one of them was assessed.

RESULTS

A total of 114 patients were included, with reconciliation errors being found in 75.4% of cases. The patients had 1397 prescribed drugs, of which 234 had discrepancies that required clarification by the clinician responsible. The clinician modified the prescription in 184 of these discrepancies, which were considered reconciliation errors. The types of error were: medication omission (139), commission (9), dose, prescription or different routes (24) and by incomplete prescription (12). Anti-anaemic drugs, vitamins, and psychoanaleptics were among the pharmacotherapeutic groups most affected by the errors.

CONCLUSIONS

The percentage of patients with multiple chronic conditions with errors is elevated. The development of methods particularly directed at patients with multiple chronic conditions manages to detect and decrease a high percentage of medication errors associated with changes of care levels.

A questionnaire to document self-medication history in adult patients visiting emergency departments

PURPOSE

To develop the first questionnaire to obtain a complete medication history by documenting self-medication history in adult patients admitted to a medical emergency department (ED).

METHODS

A Questionnaire to document Self-Medicating Behaviours (QSMB) was developed between January and September 2008 (reference period), tested and refined between October and December 2008, and used routinely between January and December 2009 (routine period) in a tertiary care medical ED. The rate of SMBs measured with QSMB during the routine period was compared to the SMB rate measured with a spontaneous reporting method during the reference period. As survey teams changed every trimester, we also analysed the evolution of SMB rate over time.

RESULTS

QSMB is divided into two parts. The first part consists of 20 closed-ended questions exploring all indications and dimensions of self-medication. The second part assesses the characteristics of each medication mentioned by the patient in the first 20 questions. The patients interviewed during reference and routine periods did not significantly differ. The routine period patients reported a third more SMBs (89.8% vs 57.6%, respectively; p < 0.0001) and twice more self-medication drugs than the reference period patients. SMB rate was significantly different between the survey teams during the reference period (p < 0.0001), but not during the routine period (p = 0.078).

CONCLUSIONS

This questionnaire complements the traditional tools that are already available to collect medication histories of prescribed drugs. It may improve the recognition of iatrogenic conditions related to self-medication, and provide support to public health efforts and research programs on self-medication.

Hospital-based medication reconciliation practices: a systematic review

BACKGROUND

Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk.

OBJECTIVES

To summarize available evidence on medication reconciliation interventions in the hospital setting and to identify the most effective practices.

DATA SOURCES

MEDLINE (1966 through February 2012) and a manual search of article bibliographies.

STUDY SELECTION

Twenty-six controlled studies.

DATA EXTRACTION

Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcome measures, and results.

DATA SYNTHESIS

Studies were grouped by type of medication reconciliation intervention-pharmacist related, information technology (IT), or other-and were assigned quality ratings using US Preventive Services Task Force criteria.

RESULTS

Fifteen of 26 studies reported pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. Six studies were classified as good quality. The comparison group for all the studies was usual care; no studies compared different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17 of 17 studies), potential adverse drug events (5 of 6 studies), and adverse drug events (2 of 2 studies) but showed an inconsistent reduction in postdischarge health care utilization (improvement in 2 of 8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a high-risk patient population.

CONCLUSIONS

Rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce. Available evidence supports medication reconciliation interventions that heavily use pharmacy staff and focus on patients at high risk for adverse events. Higher-quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.

Discrepancies in Medication Information for the Primary Care Physician and the Geriatric Patient at Discharge

BACKGROUND:

Medication discrepancies in discharge medication lists can lead to medication errors and adverse drug events following discharge.

OBJECTIVE:

To determine the incidence and type of discrepancies between the discharge letter for the primary care physician and the patient discharge medication list as well as identify possible patient-related determinants for experiencing discrepancies.

METHODS:

A retrospective, single-center, cohort study of patients discharged from the acute geriatric department of a Belgian university hospital between September 2009 and April 2010 was performed. Medications listed in the discharge letter for the primary care physician were compared with those in the patient discharge medication list. Based on the clinical pharmacist–acquired medication list at hospital admission and the medications administered during hospitalization, we determined for every discrepancy whether the medication listed in the discharge letter or the patient discharge medication list was correct.

RESULTS:

One hundred eighty-nine discharged patients (mean [SD] age 83.9 [5.7] years, 64.0% female) were included in the study. Almost half of these patients (90; 47.6%) had 1 or more discrepancies in medication information at discharge. The discharge letters were often more complete and accurate than the patient discharge medication lists. The most common discrepancies were omission of a brand name in the patient discharge medication list and omission of a drug in the discharge letter. Increasing numbers of drugs in the discharge medication list (OR 1.19; 95% CI 1.07 to 1.32; p = 0.001) and discharge letter (OR 1.18; 95% CI 1.07 to 1.32; p = 0.001) were associated with a higher risk for discrepancies.

CONCLUSIONS:

Discrepancies between the patient discharge medication list and the medication information in the discharge letter for the primary care physician occur frequently. This may be an important source of medication errors, as confusion and uncertainty about the correct discharge medications can originate from these discrepancies. Increasing numbers of drugs involve a higher risk for discrepancies. Medication reconciliation between both lists is warranted to avoid medication errors.

Effect of Medication Reconciliation at Hospital Admission on Medication Discrepancies During Hospitalization and at Discharge for Geriatric Patients

Background:

Medication discrepancies have the potential to cause harm. Medication reconciliation by clinical pharmacists aims to prevent discrepancies and other drug-related problems.

Objective:

To determine how often discrepancies in the physician-acquired medication history result in discrepancies during hospitalization and at discharge. Secondary objectives were to determine the influence of clinical pharmacists’ interventions on discrepancies and to investigate possible patient-related determinants for experiencing discrepancies.

Methods:

This was a retrospective, single-center, cohort study of patients who were admitted to the acute geriatric department of a Belgian university hospital and followed up by clinical pharmacists between September 2009 and April 2010. Patients were limited to those 65 years or older who were taking 1 or more prescription drug. Medication reconciliation at admission, during hospitalization, and at discharge was conducted by an independent pharmacist who gathered information via chart reviews.

Results:

The reconciliation process at admission identified 681 discrepancies in 199 patients. Approximately 81.9% (163) of patients had at least 1 discrepancy in the physician-acquired medication history. The clinical pharmacists performed 386 interventions, which were accepted in 279 cases (72.3%). A quarter of the medication history discrepancies (165; 24.2%) resulted in discrepancies during hospitalization, mostly because the intervention was not accepted. At discharge, 278 medication history discrepancies (40.8%) resulted in discrepancies in the discharge letter, accounting for 50.2% of all 554 discrepancies identified in the discharge letters. The likelihood for experiencing discrepancies at admission increased by 47% for every additional drug listed in the medication history.

Conclusions:

Discrepancies in the physician-acquired medication history at admission do not always correlate with discrepancies during hospitalization because of clinical pharmacists’ interventions; however, discrepancies at admission may be associated with at least half of the discrepancies at discharge. Clinical pharmacist–conducted medication reconciliation can reduce these discrepancies, provided the erroneous information in the physician-acquired medication history is corrected and each intentional change in the medication plan is well documented during hospitalization and at discharge.