Background: Accurate medication reconciliation during transitions of care can decrease medication related adverse drug events. The Joint Commission has prioritized medication reconciliation as one of the national patient safety goals. Effective pharmacist-physician-patient collaboration can improve the medication reconciliation process and thus medication safety for hospitalized patients

Purpose: 1. Develop a standardized provider-pharmacist discharge medication reconciliation process using evidence-based best practices.2. Determine the effectiveness of an inter-professional discharge medication reconciliation process on patient safety by assessing potential harm of medication reconciliation errors.

Description: This project was piloted with the general internal medicine resident teams at a community hospital affiliated with an academic medical center from 11/2016 to 6/2017. The standard of care at the time of implementation included discharge medication reconciliation performed by resident physicians (supervised by attending physicians) only. Our project involved three main components: re-design of the discharge process to include pharmacy, discharge medication reconciliation performed by pharmacy students (supervised by clinical pharmacists) after completion by physicians, and improved communication between pharmacy students and the primary team to discuss any recommendations to the patient’s discharge medication list. Students documented potential errors that they encountered during the medication reconciliation process, along with the type of error, potential harm associated with the error, and action taken by the team to prevent patient harm. Descriptive statistics were used to evaluate potential harm for adverse events. A logistic regression model was used to investigate whether the number of medications was associated with the odds of an error.

Conclusions: A total of 344 patients were discharged from the teams using the restructured discharge process. We excluded 12 observations (3 duplicates, 1 with missing information, and 8 with errors). Pharmacy students identified 66 (20%) patients with one or multiple errors. Physicians accepted the pharmacists’ recommendation to change discharge medications given there was an error for 48 patients. The probability of a patient having an error was 0.2050 (SE = 0.0225, 95% CI = (0.1622, 0.2532)). The probability of a change being made to the medication list was 0.1491 (SE = 0.0198, 95% CI (0.1120, 0.1927)). The probability of a change being made to the medication list given there was an error was 0.7273 (SE = 0.0548, 95% CI (0.6036, 0.8297)). Patients who had a higher number of discharge medications were more likely to have an error (p=0.0010). Thus, re-designing the discharge process for hospitalized patients may improve physician-pharmacist collaboration for performing discharge medication reconciliation, which may decrease potential harm to patients due to medication reconciliation errors.