Effect of Medication Reconciliation Performed by the Pharmacist on Outcomes of Medication Safety and Patient Care

Background:

Medication discrepancies, defined as unexplained differences between documented medication regimens, are highly prevalent in the hospital setting and an important contributor to adverse drug events.  In the hospital setting, 27% of all prescribing errors occur as a result of inaccurate medication histories at the time of admission. Pharmacist-recorded medication histories have been shown to result in greater accuracy and fewer medical errors throughout hospitalization. Accurate medication reconciliation reduces the rates of adverse drug reactions, medication errors, length of stay and readmission rates.  

Purpose:

During November 2014, a clinical pharmacist performed medication reconciliation on postoperative day 1 (POD1) for all orthopedic patients. This was compared to the medication history performed in pre-surgical testing (PST) by nurse practitioners followed by medication reconciliation performed upon admission to the surgical unit by hospitalists. In January 2015, the clinical pharmacist began interviewing high-risk patients in PST for medication histories.

Description:

A review of 76 patients in November 2014 revealed that medication history inaccuracies occurred when the patient took 6 prescription drugs or greater (including prescribed low dose aspirin).  These discrepancies resulted in 14 medication errors and 17 near misses.

In January-February 2015, a pharmacist intervened by capturing the pre-surgical medication history of 17 patients taking 5 or more drugs (including prescribed low dose aspirin).    Medication reconciliation was again performed by the pharmacist on POD1. The review of these patients revealed zero medication errors and 26 near misses.

Overall, from November2014-February 2015 42% of patients (n=252) were found to have a discrepancy on their admission medications when evaluated by the pharmacist on POD1.  The type of inaccuracies found were: omission 39%, wrong dose 32%, wrong frequency 16%, wrong formulation 9% and wrong drug 4%.  The source and incidence of the medication inaccuracy was the PST History and Physical (H&P): 64%, the Primary Care Provider (PCP) surgical clearance: 21%, and both the PST H&P and PCP clearance: 15%. Ultimately, these discrepancies led to 27 medication errors and 27 near misses.

Conclusions:

The goal of medication reconciliation is to obtain and maintain precise and complete medication information for a patient within and across the continuum of care.  As medication experts, pharmacists are an invaluable part of the medication reconciliation process. Medication histories taken by a pharmacist for high risk patients reduced medication errors dramatically at our institution. This allowed sufficient time for the discrepancies to be evaluated and resolved prior to admission. Based on our findings, a policy was implemented to have a clinical pharmacist complete the medication history of any patient presenting to PST for elective surgery taking 5 or more prescribed medications, including low dose aspirin.