Implementation of a pharmacist provided discharge medication reconciliation process based on risk stratification: an evaluative pilot study

Background: Maintaining accurate and complete medication reconciliations across the continuum of patient care has been identified as an important step to improve patient safety. The Joint Commission has recently revised the National Patient Safety Goal on medication reconciliation to broaden the goal to “maintain and communicate accurate patient medication information”.  Elements of this goal include obtaining a medication history, identifying and resolving discrepancies, and providing the patient or family with accurate written information and education at discharge. Due to limited resources, one strategy proposed to maximize impact on patient safety is to identify patients at “high-risk” for potential medication errors and dedicate resources to this population.

Objectives: The primary objective of this study is to evaluate the implementation of a dedicated pharmacist to discharge medication reconciliation and patient education in a pre-defined “high-risk” patient population. Other objectives include determining the frequency of discrepancies, assessing the potential for harm related to discharge medication discrepancies, and to quantify the time required to provide discharge medication reconciliation services. 

Methods: This study will take place on one surgical and one cardiology unit. Patients will be deemed “high-risk” if they meet at least two of the following criteria: 65 years of age or older, discharge disposition to a skilled living facility, taking at least 10 medications (excluding vitamins/herbals), or having at least one high-alert medication prescribed. For patients meeting criteria, the investigator will review patient information and discharge medication orders.  The physician will be contacted to clarify and correct any unintended discrepancies.  Then the investigator will provide patient education on medications. 

Results: Analysis of the first 40 patients reviewed by the investigator, 35 patients had at least one discrepancy identified on discharge medication orders.  Additional data collection is currently in progress.    

Conclusion: Data collection currently in progress and will be completed by January 31^st, 2012.