Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting.

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Lillian L. Smith
Juan F. Mosley II
Sonia Lott
Ernie Cyr
Ramid Amin
Emily Everton
Abdullah Islami
Linh Phan
Opeyemi Komolafe


Medication Reconciliation, Patient Admission, Pharmacy Service, Hospital, Medication Errors, Pharmacists, Students, Pharmacy, United States


Objective: To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting.

Methods: This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment.

Results: During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04).

Conclusion: Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved.


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1. The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alert. 2006;(35):1-2.

2. USP Patient Safety CAPSLink. US Pharmacopeia. Available at: (accessed on November 4, 2015).

3. Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296(15):1858-1866.

4. Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. The costs of adverse drug events in community hospitals. Jt Comm J Qual Patient Saf. 2012;38(3):120-126.

5. Bootman L, Cronenwett LR. Preventing Medication Errors. Institute of Medicine Report Brief. Jan. 2006. Web. 12 Sept. 2014.

6. Lau HS, Florax C, Porsius AJ, de Boer A. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. Br J Clin Pharmacol. 2000;49(6):597-603.

7. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424-429.

8. Pippins JR, Gandhi TK, Hamann C, Ndumele C, Labonville SA, Diedrichsen EK, Carty MG, Andrew S. Karson, Bhan I, Coley CM, Liang CL, Turchin A, McCarthy PC, Schnipper JL. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414-1422. doi: 10.1007/s11606-008-0687-9

9. Hayes BD, Donovan JL, Smith BS, Hartman CA. Pharmacist-conducted medication reconciliation in an emergency department. Am J Health Syst Pharm. 2007;64(16):1720-1723.

10. Lu Y, Clifford P, Bjorneby A, Thompson B, VanNorman S, Won K, Larsen K. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-820. doi: 10.2146/ajhp120050

11. Buckley MS, Harinstein LM, Clark KB, Smithburger PL, Eckhardt DJ, Alexander E, Devabhakthuni S, Westley CA, David B, Kane-Gill SL. Impact of clinical pharmacy admission medication reconciliation program on medication errors in “high-risk” patients. Ann Pharmacother. 2013;47(12):1599-1610. doi: 10.1177/1060028013507428

12. Lee KP, Hartridge C, Corbett K, Vittinghoff E, Auerbach AD. “Whose job is it, really?” physicians’, nurses’, and pharmacist’ perspectives on completing inpatient medication reconciliation. J Hosp Med. 2015;10(3):184-186. doi: 10.1002/jhm.2289

13. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health Syst Pharm. 2002;59(22):2221-2225.

14. Lancaster JW, Grgurich PE. Impact of student pharmacist on the medication reconciliation process in high –risk hospitalized general medicine patients. Am J Pharm Educ. 2014;78(2):34. doi: 10.5688/ajpe78234

15. Mergenhagen KA, Blum SS, Kugler A, Livote EE, Nebeker JR, Ott MC, Signor D, Sung S, Yeh J, Boockvar KS. Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events. Am J Geriatr Pharmacother. 2012;10(4):242-250. doi: 10.1016/j.amjopharm.2012.06.001

16. Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Medication reconciliation at an academic medical center: Implementation of a comprehensive program from admission to discharge. Am J Health Syst Pharm. 2009;66(23):2126-2131. doi: 10.2146/ajhp080552

17. CAHPS Hospital Survey. Background and About Survey. (accessed 2015 Jan 27).

18. Lubowski TJ, Cronin LM, Pavelka RW, Briscoe-Dwyer LA, Briceland LL, Hamilton RA. Effectiveness of a medication reconciliation project conducted by PharmD students. Am J Pharm Educ. 2007;71(5):94.

19. Smith SB, Mango MD. Pharmacy-based medication reconciliation program utilizing pharmacists and technicians: a process improvement initiative. Hosp Pharm. 2013;48(2):112-9. doi: 10.1310/hpj4802-112.test

20. George LJW, Senturk-Raif R, Hodgkinson MR, Emmerton M, Larmour I. Impact of a surgical preadmission clinic pharmacist on the quality of medication management from preadmission to discharge: a randomized controlled study. J Pharm Pract Res. 2011;41(3): 212-216.

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