Background: Adverse drug events (ADEs) result in more than 770,000 injuries and deaths each year and cost up to $5.6 million per hospital, depending on size. The hospital admission is often where the patient is most vulnerable to ADEs. Medication reconciliation on admission is a formal process by which efforts are made to ascertain a complete and accurate list of a patient’s current home medications and evaluate their continued appropriateness in the inpatient setting. In its 2011 update, the Joint Commission incorporated medication reconciliation as a National Patient Safety Goal. The ability to obtain a comprehensive pre-admission medication list is often challenging and time-consuming due to many confounding variables including poly-pharmacy, non-compliance, over-the-counter (OTC) usage, poor recall of medication history, and limited family and pharmacy access. As a result, the new medication regimen prescribed at the time of admission, as well as the discharge medication list, is prone to errors. Additionally, it takes a significant amount of time on the part of the admitting team, in our case hospitalists, to obtain even an incomplete pre-admission medication list.

Purpose: An interdisciplinary approach involving direct collaboration between hospitalists and pharmacists was implemented in an effort to reduce the frequency of medication-related errors and to improve the efficiency of the admission process.

Description: In this approach, a pharmacist obtains home medication lists for patients admitted to the medicine service through the Emergency Department (ED) of a tertiary care, 500+ bed urban/suburban teaching hospital. The medication history team consists of 5 full-time pharmacists who work 7 days a week from 6a-12a. To identify patients, the pharmacists carry an admit pager and regularly communicate with the Hospitalist-in-Charge to prioritize their workflow. The pharmacist perform a complete medication history review including all prescription, herbal, and OTC medication use, as well as evaluate medication adherence, appropriate dosing, review for potential interactions, and the presence of adverse drug reactions. The complete medication list is electronically entered by the pharmacist into the patient’s outpatient medication history in the EMR who then communicates pertinent recommendations verbally to the admitting hospitalist. That hospitalist then completes the medication reconciliation.

Conclusions: Over the 10-month study period, we have been able to demonstrate a $600,000 cost avoidance based on the number of discrepancies identified by pharmacy. Additionally, the medication history team has reduced the average time it takes the hospitalists to complete an admission by 10-25 minutes, leading to more timely care, improved patient throughput and possibly the completion of more admissions per shift. The discharging providers have also noted a decrease in time to completion of the discharge documentation due to the improved accuracy of the outpatient medication list. Future initiatives will focus on more accurately measuring the direct and indirect cost savings to more objectively support the business plan for admission pharmacists.