Medication reconciliation improved, adverse events decreased

Physicians came to rely on pharmacists' reconciliation

Research conducted by Temple University Hospital and Temple University School of Pharmacy has found that having a pharmacist make rounds with a medicine team improves the accuracy of medication reconciliation and decreases adverse events due to medication error.

Nima M. Patel, PharmD, clinical assistant professor in the Temple University School of Pharmacy, tells Drug Formulary Review the study was conducted with patients admitted directly to a medicine team with a pharmacist. Adult patients were included who were taking at least three chronic medications and who spoke English. Patients transferred to the service who were unable to give a medication history or were unable to be interviewed by the pharmacist within 48 hours of admission were excluded.

Physicians completed the patients' medication history, and a pharmacist interviewed each patient afterward. Discrepancies in medication reconciliation were classified as appropriate or inappropriate. Inappropriate discrepancies without reasonable cause were recorded and categorized according to type of discrepancy such as omission or incorrect dose, route, or frequency.

Patel says the study involved 45 patients, the majority being African American (76%) and female (67%). Patients were taking an average of seven medications.

To obtain a medication history, the patient's community pharmacy was called 38% of the time and the patient had the medication bottles or a list of medications 33% of the time.

The team found a total of 130 medication discrepancies, including 74 inappropriate discrepancies, with a mean of 1.6 per patient. Patel says most inappropriate discrepancies were due to omission of a medication (69%). There was a moderate correlation between the number of inappropriate discrepancies and the number of medications. Discrepancies contributed to temporary harm in 18% of the cases. Most errors (70%) led to no harm but required increased monitoring.

Patel tells Drug Formulary Review that pharmacists are successful in improving medication reconciliation accuracy and decreasing adverse events because of their knowledge of medications and the thorough way in which they approach taking a medication history.

Physician residents take medication histories

At Temple University Hospital, she says, physician residents are responsible for medication reconciliation. In the research, the residents did the initial work but then a pharmacy resident interviewed the patients and took whatever other steps were necessary, such as contacting the community pharmacy or talking with the patient's family. The pharmacy resident compared the medication reconciliation she obtained with that obtained by the physician resident and recorded the discrepancies.

Asked how the physicians responded to having their work checked by pharmacists, Patel says the physicians were appreciative that the pharmacists took the initiative to do their own medication reconciliation and suggested pharmacists should carry out the function all the time.

"The doctors came to rely on the pharmacy resident to do the reconciliation process and were less interested in doing it themselves," Patel says. "We received very positive feedback."

Patel says one of the reasons they conducted the research was to demonstrate the practice's value to hospital administration in hopes of obtaining support for making it a permanent change. She says they were able to demonstrate the improvements that occurred as a result of having pharmacists involved in the medication reconciliation process, and have requested funds with which to hire a full-time pharmacist to be dedicated to this process. They also are looking at having pharmacy students become involved in the process.

[Editor's note: Contact Dr. Patel at (215) 707-2319 or e-mail]