Making the case for early medication reconciliation by clinical pharmacists

Background: In 2005, the Joint Commission required health care facilities to implement medication reconciliation processes in line with stated National Patient Safety Goals (NPSG). Inaccurate medication reconciliation may increase the potential for errors, which may be associated with preventable adverse drug events (ADEs). Pharmacist’s involvements may play a pivotal role in preventing these errors.

Purpose: To highlight the impact of medication reconciliation conducted by clinical pharmacists in Hamad General Hospital (HGH) on reducing adverse drug events during admission and transfer by identifying different types of interventions.

Methods: Clinical pharmacists’ interventions, done through a medication reconciliation process in the first 24 hours of admission or transfer, in one adult general medical unit and a pediatric hematology and oncology unit, were collected over 1 month. For each patient, both inpatient and outpatient records were reviewed. Clinical pharmacists conducted interviews with the patient or caregiver to review their medications. The collected data were then compared with the current medication list prescribed after admission or transfer. All information was documented in a special medication reconciliation form.

Results: For the 52 patients interviewed, the total number of medications reconciled was 263. Of these, 93 medications (35%) required the intervention of clinical pharmacists. Omission was the most common type of error, having been the reason for 26 interventions (27%), followed by wrong doses, which required 23 interventions (23%). Medications with no indication accounted for 14 interventions (15%). Drug classes with the highest number of discrepancies included antimicrobials (17%), vitamins (15%), analgesics (14%) and cardiovascular medications (13%).

Conclusion: The clinical pharmacist's medication reconciliation conducted in the first 24 hours of admission or transfer can reduce ADEs by substantially reducing the incidence of medication errors .This pharmacist involvement in medication reconciliation may have a great impact on  the cost effectiveness and quality of healthcare.