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Purpose: To evaluate the potential role of pharmacists and student pharmacists in conducting medication reconciliation services in a primary care clinic. The requirement for health systems to conduct medication reconciliation provides both an educational and service opportunity for pharmacists. This service is part of an existing learning experience for students and residents designed to improve patient interview skills, identify medication discrepancies, identify and resolve drug related problems.
Methods: Clinic staff identified recently discharged patients and contacted them to participate in a onetime medication reconciliation visit with a pharmacist. Patients were scheduled prior to the hospital follow-up visit with the physician. Medication discrepancies and recommendations for resolving drug related problems were communicated with the physician.
Results: Thirty seven patients were seen between September 2011 and May 2012. Interventions were categorized into twelve actions that could be performed to prevent adverse drug events and unwanted outcomes. The most common interventions were non adherence/underuse (8), order lab (10) and identifying untreated medical problems (8). The most common actions taken were to discontinue a prescription (8), new prescription (6), order tests (8) and education (12). The types of lab tests that were ordered included blood pressure, blood glucose, thyroid levels, potassium and CBC.
Conclusions: Primary care based pharmacists and student pharmacists can identify and resolve drug related problems during the transition between hospital and home. At least one intervention was detected for each patient. Having access to medical records in outpatient and hospital databases and having the drug knowledge necessary to address interventions allowed us to evaluate the drug therapy needs of patients in this transition. Future plans include tracking outcomes of the service, particularly for reduced readmission rates.