Background: Acutely-ill and multimorbid patients are frequently exposed to unintended medication errors after admission and their impacts on patient safety are profound. Designated ward-pharmacists as team members of our Hospital Medicine Center reconcile medications of hospitalized patients by identifying discrepancies in patients’ current medications and the medication used in acute care in emergency departments or before admission. The purpose of this study was to evaluate the clinical and economic impact of medication reconciliation by designated ward-pharmacist in the hospitalist managed acute medical unit at a tertiary hospital in Korea.
Methods: In this retrospective observational study, intervention records were compared before (April to August 2018) and after (April to August 2019) the implementation of medication reconciliation by designated ward-pharmacists. The pharmacist’s interventions were evaluated by the frequencies of interventions, types of interventions and hospitalists’ acceptance rate. Clinical impact of interventions was estimated by the length of stay and the 30-day readmission rate. The Cost avoidance was calculated by taking into account the cost of potential one-day extension of hospitalization without a pharmacist intervention and the clinical significance of the intervention categorized into five levels (potentially lethal, serious, significant, minor, no error).
Results: After the designated pharmacist-led medication reconciliation service, frequencies of the intervention was significantly increased from 3.9% (n=59/1327 patients) to 22.1% (n=537/1378 patients) (p<0.001). The range of intervention types has also been extended from detecting dosing errors to noticing medication discrepancies between pre-admission and hospitalization (22.7%), potentially inappropriate medication use in the elderly (13.1%), and possible adverse drug reactions (12.5%). Over two-thirds of the types of interventions accepted by hospitalists showed clinical significance above “significant”. The median length of stay decreased from 9.6 days to 8.9 days (p=0.024) and the 30-day readmission rate declined significantly from 7.8% to 4.8% (p=0.046). During the five months following the designated pharmacist's activities, the cost avoidance was 22,381,422 won (19,137 USD).
Conclusions: We showed that implementation of designated ward-pharmacists-led medication reconciliation can improve the numbers and extent of the intervention and potentially significant medication errors were accepted by hospitalists. Successful performance of medication reconciliation can have positive clinical and economic impact in the hospitalist managed acute medical unit.