Pharmacists conduct med rec at admission

Error rates decrease

Pharmacist involvement in medication reconciliation is so crucial to patient safety that one 450-plus-bed Wisconsin hospital invested considerable staff resources to make this a smooth process from admission through discharge.

"Pharmacists as medication experts are ideal to do medication reconciliation, but it is a labor-intensive process," says Kristin Hanson, MS, RPh, medication safety officer at Froedtert Hospital in Milwaukee, WI.

In a recently published study, the hospital showed that the medication reconciliation process has resulted in a reduction of medication errors from 90% to 47% on the surgical unit since pharmacists were assigned to this role. Also, the error rate decreased from 57% to 33% on the medicine unit.1

"We've made significant improvements in patient safety, and I feel confident that this is how we want to handle it," Hanson says. "This is not an inexpensive and easy improvement to do, but we feel it's the right thing to do."

After collecting some preliminary data in 2005, the hospital decided it made sense from a quality and safety perspective to have pharmacists involved in medication reconciliation for all patients, she adds.

The hospital leadership's decision was reinforced by The Joint Commission's focus on admission and transfer in its National Patient Safety goals and by the Institute for Healthcare Improvement's 5 Million Lives Initiative's focus on reducing medical harm, Hanson notes.

"We decided to start efforts with the admission history and get as accurate a medication history as we could when the patient is admitted," Hanson says. "The key piece is getting that accurate medication list for what the patient is on at home."

The hospital's administration saw the pharmacy's proposal to have pharmacists conduct the medication history at admission, spending an average of 20 minutes per patient, and agreed to fund 3.5 additional FTEs of pharmacist time, she adds.

"With the administration's support and with safety being a top priority, these were our new positions," Hanson says.

All of the pharmacists at Froedtert Hospital are clinical pharmacists who work in a decentralized environment. They are involved with 11 decentralized teams in inpatient care, divided by intensive care units (ICUs) and floors. So each pharmacist is trained to obtain medication histories at admission.

Since pharmacists became involved, the hospital has identified and addressed more medication discrepancies at admission and discharge than previously, says Carolyn Oxencis, PharmD, clinical pharmacist at Froedtert Hospital.

"When I came on board, my portion of the project was admission medication history and reconciliation of orders," Oxencis says. "I collected information from the regular patient care unit and different patient populations."

Oxencis found that 53% of patient cases had some type of medication discrepancy, including both intentional and unintentional.

The intentional discrepancies would be when a physician purposely changed a patient's medication after hospital admission because the hospital either had a different drug on the formulary or because the physician needed to hold back on the patient's regular drugs for safety issues. An example would be a physician stopping warfarin or aspirin when a patient was admitted for a bleeding problem.

But the unintentional discrepancies could pose safety problems.

For instance, Oxencis recalls reviewing the home and hospital-initiated medications of a new patient and finding that the hospital surgeon had prescribed Coumadin despite the patient having a normal INR and no history of clotting.

"When I did further digging into it, I found out the patient was taking Coricidin, an over-the-counter cough and cold medication, and the doctor had misunderstood," Oxencis says.

The doctor had read the order incorrectly, thinking Coricidin was Coumadin.

"So the doctor was about to give the patient an anticoagulant when all the patient had been taking was Tylenol and a cold medicine," she adds. "This made me realize how easily a medication error could occur."

By having a pharmacist involved in the admission medication reconciliation, a potential adverse event was averted.

"There are all types of different errors or discrepancies that can occur in a hospital," Oxencis notes. "Each of these could have a potentially different impact on an individual patient."

Examples of potential medication discrepancies include the following:

- wrong strength;

- wrong directions;

- unacceptable abbreviation;

- missing strength;

- missing route of administration;

- missing directions;

- inpatient medication omitted;

- home medication omitted.1

Froedtert Hospital's pharmacist-conducted medication reconciliation was implemented for all inpatients admitted to the hospital, except for patients admitted for observation or 24-hour admits, Hanson says.

"We did a few extensive pilots before implementing it," she adds. "And we did extensive training for pharmacists on how to do the best job and finding the best resources to pull from."

Each pharmacist attended a training session that lasts up to two hours, and they were given competency testing.

"Then there were also some one-on-one training and observation," Hanson says. "We've built in this training for all new pharmacists now."

The pharmacy department added the additional pharmacist FTEs into its practice model and made patient care area pharmacists responsible for conducting histories of patients in their area.

"Rather than having one person do all of the medication histories and reconciliations in the hospital, each pharmacist does it for their patients," Hanson says.

Pharmacists take patients' medication histories when they're admitted, but are also available for consultations during the patients' stay and at discharge. The medication history information is placed in the hospital's electronic medical record, which makes it easier for physicians to review.

"When we started this it was a much more paper-based system," Hanson notes.

"Because we have such a complete medication history up-front and throughout the continuum of care, it should provide quite accurate information for the discharge component," she says. "And now with the electronic piece improving the workflow, they don't need to have a pharmacist involved intimately with every single patient."

There are some plans to expand the pharmacist's role in the hospital, including adding more pharmacist time to working in the emergency department and putting a pharmacist in the pre-operative clinic, Hanson says.

"Patients come in to the clinic a week or two before surgery, which is the ideal time to interview them about their medications," she says.


Murphy EM, Oxencis CJ, Klauck JA, et al. Medication reconciliation at an academic medical center: Implementation of a comprehensive program from admission to discharge. Am J Health-Syst Pharm 2009;66:2126-2131.