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Methods: This will be a before and after study design in hospitalized patients on the general medicine service, unit 55 at Emanuel Hospital in Portland, Oregon. Patients discharged before the intervention had their discharge medication reconciliation completed by a physician and their medication counseling provided by a nurse. Post-intervention patients will receive medication reconciliation and counseling by a pharmacist before discharge home, in addition to the physician performing their usual role.
Results: The primary outcome will be change in patient satisfaction score based upon a phone survey done 7-10 days after discharge by an independent source. Secondary objectives are number and type of medication discrepancies and cost-savings associated with those discrepancies found upon medication reconciliation by a pharmacist. In the initial data collection, pharmacists have been successfully able to counsel 36% of all patients discharged home. Patient satisfaction scores are collected on a quarterly basis, thus are not available at this time. The largest intervention made by pharmacists has been answering basic medication questions for the patient and family. This occured more than 90% of the time during all counseling sessions.
Conclusion: Pharmacist lead discharge medication reconciliation and counseling has provided our patients an opportunity for questions and clarifications about their medications immediately prior to being discharged from the hospital. The expectation is that this will improve patient satisfaction, while also providing an avenue for pharmacists to intervene on medication discrepancies. Our complete results and conclusion will be available by April 2012.