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1.  Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients admitted to hospital 
BMJ Open  2013;3(1):e001563.
Objective
To evaluate the cost effectiveness of a multidisciplinary team including a pharmacist for systematic medication review and reconciliation from admission to discharge at hospital among elderly patients (the Lund Integrated Medicines Management (LIMM)) in order to reduce drug-related readmissions and outpatient visits.
Method
Published data from the LIMM project group were used to design a probabilistic decision tree model for evaluating tools for (1) a systematic medication reconciliation and review process at initial hospital admission and during stay (admission part) and (2) a medication report for patients discharged from hospital to primary care (discharge part). The comparator was standard care. Inpatient, outpatient and staff time costs (Euros, 2009) were calculated during a 3-month period. Dis-utilities for hospital readmissions and outpatient visits due to medication errors were taken from the literature.
Results
The total cost for the LIMM model was €290 compared to €630 for standard care, in spite of a €39 intervention cost. The main cost offset arose from avoided drug-related readmissions in the Admission part (€262) whereas only €66 was offset in the Discharge part as a result of fewer outpatient visits and correction time. The reduced disutility was estimated to 0.005 quality-adjusted life-years (QALY), indicating that LIMM was a dominant alternative. The probability that the intervention would be cost-effective at a zero willingness to pay for a gained QALY compared to standard care was estimated to 98%.
Conclusions
The LIMM medication reconciliation (at admission and discharge) and medication review was both cost-saving and generated greater utility compared to standard care, foremost owing to avoided drug-related hospital readmissions. When implementing such a review process with a multidisciplinary team, it may be important to consider a learning curve in order to capture the full advantage.
doi:10.1136/bmjopen-2012-001563
PMCID: PMC3553390  PMID: 23315436
Clinical Pharmacology
2.  Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors 
ABSTRACT
Background
Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.
Objective
To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list.
Design, Participants
We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL–CVD) Study.
Main Measures
Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors.
Key Results
On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00– 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10–1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30–0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19–1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01–1.11).
Conclusions
Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.
doi:10.1007/s11606-012-2003-y
PMCID: PMC3403136  PMID: 22350761
medication reconciliation; hospital; medication errors; admission; discharge
3.  Effect of Education on the Recording of Medicines on Admission to Hospital 
BACKGROUND
The inaccurate recording of medicines on admission to hospital is an important cause of medication error. Medication reconciliation has been used to identify and correct these errors.
OBJECTIVE
To determine if a multimodal intervention involving medication reconciliation with real-time feedback and education would reduce the number of errors made by medical staff when recording medicines at the time of admission to hospital.
DESIGN
Observational study.
PARTICIPANTS
Patients admitted to the general medical wards of a teaching hospital were studied prospectively. Patients ≥75 years of age and on ≥5 medications were identified as the ‘target group.’
INTERVENTION
After admission, a second medication history was taken, and discrepancies were identified and communicated to the medical teams. An educational intervention to encourage prescribers to obtain accurate medication histories was conducted at the same time.
MEASUREMENTS
The discrepancy rate was measured before and after the intervention.
MAIN RESULTS
There were 470 admissions in the ‘target group.’ Three hundred and thirty-eight of the admissions (71.9%) had one or more unintentional discrepancies. Although many discrepancies had little potential to cause harm, 33% were rated as clinically significant. During the study the discrepancy rate (prior to reconciliation) fell from 2.6 (SD 2.6) to 1.0 (SD 1.1) per admission (p < 0.0001). This decline in discrepancy rate remained significant (p = 0.001) even when only clinically important discrepancies were included. The proportion of admissions with one or more clinically important discrepancies also decreased during the study from 46% to 24% (p = 0.023).
CONCLUSIONS
Errors in the recording of medicines at the time of hospital admission are common. Combining the feedback provided by medication reconciliation with prescriber education reduced the error rate. This approach may be useful when the resources are not available to perform medication reconciliation for all patients admitted to hospital.
doi:10.1007/s11606-010-1317-x
PMCID: PMC2869408  PMID: 20237959
medical education; medical errors; medical record system
4.  Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission 
Background
This study was designed to determine risk factors and potential harm associated with medication errors at hospital admission.
Methods
Study pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications. Discrepancies resulting in order changes were considered errors. Logistic regression was used to analyze the association of patient demographic and clinical characteristics including patients’ number of pre-admission prescription medications, pharmacies, prescribing physicians and medication changes; and presentation of medication bottles or lists. These factors were tested after controlling for patient demographics, admitting service and severity of illness.
Results
Over one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful. In logistic regression analysis, patient’s age ≥65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09–4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14–1.29) were significantly associated with errors potentially requiring monitoring or causing harm. Presenting a medication list (OR, 0.35; 95% CI, 0.19–0.63) or bottles (OR, 0.55; 95% CI, 0.27–1.10) at admission was beneficial.
Conclusion
Over one-third of the patients in our study had a medication error at admission, and of these patients, 85% had errors originate in their medication histories. Attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists.
doi:10.1007/s11606-010-1256-6
PMCID: PMC2855002  PMID: 20180158
medication reconciliation; medication errors; medication history taking
5.  Pharmacy-Based Medication Reconciliation Program Utilizing Pharmacists and Technicians: A Process Improvement Initiative 
Hospital Pharmacy  2013;48(2):112-119.
Background:
Pharmacists and pharmacy technicians have an opportunity to impact the quality of the medication histories and improve patient safety by ensuring accurate medication lists are obtained and complete reconciliation has occurred with the admission medication orders by owning the admission medication reconciliation process.
Objective:
To compare the quality of a pharmacy-based medication reconciliation program on admission utilizing pharmacists and technicians to the usual multidisciplinary process.
Methods:
This was a retrospective chart review process improvement study at a 186-bed tertiary care inpatient facility. Primary outcomes included both the accuracy of pre-admission medications listed and the reconciliation of those medications with admission inpatient orders. Technicians obtained patient medication histories. Pharmacists checked the technician-obtained medication histories and ensured reconciliation of those medications with admission orders.
Results:
Medication accuracy increased from 45.8% to 95% per patient (P < .001) and medication reconciliation increased from 44.2% to 92.8% (P < .001) and remained above benchmark.
Conclusion:
A pharmacy-based medication reconciliation program utilizing both pharmacists and technicians significantly increased the accuracy and reconciliation of medications on admission. These gains were maintained for the duration of the 6-month period studied and beyond per continued process improvement data collection.
doi:10.1310/hpj4802-112
PMCID: PMC3839485  PMID: 24421448
admission; medication reconciliation; process improvement
6.  Decreasing Medication Discrepancies Between Outpatient and Inpatient Care Through the Use of Computerized Pharmacy Data 
The Permanente Journal  2007;11(2):31-34.
Context: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) instituted a new regulation in 2006 to improve patient safety by decreasing medication errors. This requires a process for obtaining and documenting a complete list of each patient's current medications at hospital admission and communicating this list to the next clinician (“Medication Reconciliation”).
Objective: We sought to determine whether medication discrepancies between outpatient and inpatient care can be decreased through the use of computerized pharmacy data.
Method: We evaluated outpatient medication prescriptions in 2000 and 2004 using computer-generated data for patients admitted from an Emergency Department to a medical ward. The hospital records and pharmacy data were reviewed to determine which ambulatory medications were ordered at admission, continued as an out-patient, and refilled three months after discharge. In 2004 additional computerized pharmacy data were provided to attending physicians. Ambulatory care “essential prescription medication groups” (cardiac, chronic obstructive pulmonary disease, asthma, diabetes, and neurologic) were also evaluated. Medication discrepancies for the years 2000 and 2004 were compared in several categories.
Results: Medication discrepancies were found in all evaluated categories in 2000. The follow-up study showed a decrease in discrepancies for nearly all categories.
Conclusion: Results show that use of outpatient pharmacy data can decrease medication discrepancies in compliance with current JCAHO requirements.
PMCID: PMC3057734  PMID: 21461091
7.  Medication Reconciliation Accuracy and Patient Understanding of Intended Medication Changes on Hospital Discharge 
Journal of General Internal Medicine  2012;27(11):1513-1520.
ABSTRACT
BACKGROUND
Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding.
OBJECTIVE
To determine the prevalence of medication reconciliation errors and patient misunderstanding of discharge medications.
DESIGN
Prospective cohort study
SUBJECTS
Patients over 64 years of age admitted with heart failure, acute coronary syndrome or pneumonia and discharged to home.
MAIN MEASURES
We assessed medication reconciliation accuracy by comparing admission to discharge medication lists and reviewing charts to resolve discrepancies. Medication reconciliation changes that did not appear intentional were classified as suspected provider errors. We assessed patient understanding of intended medication changes through post-discharge interviews. Understanding was scored as full, partial or absent. We tested the association of relevance of the medication to the primary diagnosis with medication accuracy and with patient understanding, accounting for patient demographics, medical team and primary diagnosis.
KEY RESULTS
A total of 377 patients were enrolled in the study. A total of 565/2534 (22.3 %) of admission medications were redosed or stopped at discharge. Of these, 137 (24.2 %) were classified as suspected provider errors. Excluding suspected errors, patients had no understanding of 142/205 (69.3 %) of redosed medications, 182/223 (81.6 %) of stopped medications, and 493 (62.0 %) of new medications. Altogether, 307 patients (81.4 %) either experienced a provider error, or had no understanding of at least one intended medication change. Providers were significantly more likely to make an error on a medication unrelated to the primary diagnosis than on a medication related to the primary diagnosis (odds ratio (OR) 4.56, 95 % confidence interval (CI) 2.65, 7.85, p < 0.001). Patients were also significantly more likely to misunderstand medication changes unrelated to the primary diagnosis (OR 2.45, 95 % CI 1.68, 3.55), p < 0.001).
CONCLUSIONS
Medication reconciliation and patient understanding are inadequate in older patients post-discharge. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis. Efforts to improve medication reconciliation and patient understanding should not be disease-specific, but should be focused on the whole patient.
doi:10.1007/s11606-012-2168-4
PMCID: PMC3475816  PMID: 22798200
quality of care; acute coronary syndrome; heart failure; pneumonia; discharge instructions; medication reconciliation; adverse drug events; adverse events; patient education
8.  Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists 
Background:
Obtaining an accurate and complete medication list (i.e., the best possible medication history [BPMH]) is the first step in completing medication reconciliation. The ability of pharmacy technicians to obtain medication histories, relative to that of pharmacists, has not been formally assessed.
Objectives:
To determine whether pharmacy technicians at the authors’ institution could obtain a BPMH as accurately and completely as pharmacists and if both groups met national norms for unintentional discrepancies and the success index for medication reconciliation.
Methods:
Pharmacy technicians were trained in obtaining a BPMH at the beginning of the study, before any patients were enrolled. Patients presenting to the emergency department were prospectively enrolled to be interviewed separately by both a pharmacist and a technician, with information recorded on standard medication reconciliation forms. The completed forms for each patient were compared following each set of interviews, and discrepancies were clarified with the patient.
Results:
Fifty-nine patients were included in the study, and 3 pharmacists and 2 technicians obtained the histories. There was no significant difference between pharmacists and technicians in terms of discrepancies involving prescription drugs (χ2 = 0.52, df = 1, n = 118, p = 0.47, Cramer’s V for effect size = 0.07) or over-the-counter medications (χ2 = 0.09, df = 1, n = 118, p = 0.77, Cramer’s V = 0.03). The mean number of discrepancies per patient did not differ significantly between the pharmacists and technicians (t = 0.15, df = 58, p = 0.88 for prescription drugs; t = −0.22, df = 58, p = 0.83 for over-the-counter products). For both groups, the number of unintentional discrepancies per patient was significantly lower and the success index for medication reconciliation significantly higher than the national average.
Conclusions:
Trained pharmacy technicians at the authors’ institution were able to obtain a BPMH with as much accuracy and completeness as pharmacists. Both groups were significantly superior to the national average in terms of unintentional discrepancies and success index for medication reconciliation.
PMCID: PMC2999367  PMID: 22479003
medication reconciliation; pharmacy technician; best possible medication history; BPMH; emergency department; bilan comparatif des médicaments; technicien en pharmacie; meilleur schéma thérapeutique possible; MSTP; service des urgences
9.  Unintended Medication Discrepancies Associated with Reliance on Prescription Databases for Medication Reconciliation on Admission to a General Medical Ward 
Background:
In a recent study, 50% of the patients who were admitted to a hospital’s general medicine ward had at least one error in medication orders at the time of admission related to inaccuracies in the medication history. The use of computerized prescription databases has been suggested as a way to improve medication reconciliation at the time of admission.
Objective:
To quantify and describe unintended discrepancies between a best possible medication history and medications ordered on admission to the general medicine ward in a hospital with routine access to a provincial outpatient prescription database (British Columbia’s PharmaNet).
Methods:
This prospective study involved 20 patients who were regularly using at least 4 prescription medications before admission to hospital. The best possible medication history for each patient (based on a review of the medical chart and the PharmaNet record and an interview with the patient) was compared with the physician’s admission orders to identify any discrepancies. The frequency and perceived severity of discrepancies, graded independently by 3 physicians, were compared with observations from a similar study conducted at a hospital where a prescription database was not available.
Results:
The 20 patients were recruited between September 2005 and January 2006. For 8 patients (40%), information in the PharmaNet database was consistent with the prescription medication list obtained during the best possible medication history at the time of admission. For the other 12 patients, a total of 30 unintended discrepancies were identified, 13 (43%) of which were classified as having potential for moderate or severe harm. The proportion of patients with unintended discrepancies was similar to that for the comparison cohort (60% versus 54%). Although the percentage of discrepancies involving omissions was lower than in the comparison population (37% versus 46%), these results were offset by a higher proportion of commission discrepancies (27% versus 0%).
Conclusion:
Unintended discrepancies were frequent, despite use of the PharmaNet database at the time of admission. Inconsistencies between the PharmaNet record and patients’ actual medication use, coupled with failure to verify PharmaNet data with patients, were likely contributing factors.
PMCID: PMC2826955  PMID: 22478906
medication history; medication reconciliation; prescription database; medication errors; histoire médicamenteuse; bilan comparatif des médicaments; base de données sur les médicaments d’ordonnance; erreurs de médication
10.  Design and Implementation of an Application and Associated Services to Support Interdisciplinary Medication Reconciliation Efforts at an Integrated Healthcare Delivery Network 
Confusion about patients’ medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.
doi:10.1197/jamia.M2142
PMCID: PMC1656965  PMID: 17114640
11.  A Review of Medication Reconciliation Issues and Experiences with Clinical Staff and Information Systems 
Applied Clinical Informatics  2010;1(4):442-461.
Medication reconciliation was developed to reduce medical mistakes and injuries through a process of creating and comparing a current medication list from independent patient information sources, and resolving discrepancies. The structure and clinician assignments of medication reconciliation varies between institutions, but usually includes physicians, nurses and pharmacists. The Joint Commission has recognized the value of medication reconciliation and mandated implementation in 2006; however, a variety of issues have prevented simple, easy, and universal implementation. This review references issues related to the development and the implementation of medication reconciliation including: – the need of a system or standard for accurate drug identification to create a definitive ‘gold standard’ patient medication list, – identifying stakeholders of medication reconciliation within the institution and contrasting staff interest and participation with institutional resources, – observations and opportunities of integrating medication reconciliation with the electronic patient health record, and – summarizing a series of institutions experiences developing and implementing medication reconciliation. Last, as medication reconciliation becomes a regular process within medical centers, key concepts for effective implementation are discussed.
doi:10.4338/ACI-2010-02-R-0010
PMCID: PMC3633312  PMID: 23616853
Medication reconciliation; medical errors; patient safety; medical informatics; drug errors; pharmaceuticals
12.  Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS) 
Background
Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation.
Methods
Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders.
Discussion
At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes.
Trial registration
Clinicaltrials.gov identifier NCT01337063
doi:10.1186/1472-6963-13-230
PMCID: PMC3698100  PMID: 23800355
Medication reconciliation; Hospitalization; Quality improvement; Care transitions
13.  Reconcilable differences: correcting medication errors at hospital admission and discharge 
Quality & Safety in Health Care  2006;15(2):122-126.
Background
Medication errors at the time of hospital admission and discharge are common and can lead to preventable adverse drug events. The objective of this study was to describe the potential impact of a medication reconciliation process to identify and rectify medication errors at the time of hospital admission and discharge.
Methods
Sixty randomly selected patients were prospectively enrolled at the time of admission to a Canadian community hospital. At admission, patients' medication orders were compared with pre‐admission medication use based on medication vials and interviews with patients, caregivers, and/or outpatient healthcare providers. At discharge, pre‐admission and in‐patient medications were compared with discharge orders and written instructions. All variances were discussed with the prescribing physician and classified as intended or unintended; unintended variances were considered to be medication errors. An internist classified the clinical importance of each unintended variance.
Results
Overall, 60% (95% CI 48 to 72) of patients had at least one unintended variance and 18% (95% CI 9 to 28) had at least one clinically important unintended variance. None of the variances had been detected by usual clinical practice before reconciliation was conducted. Of the 20 clinically important variances, 75% (95% CI 56 to 94) were intercepted by medication reconciliation before patients were harmed.
Discussion
Unintended medication variances at the time of hospital admission and discharge are common and clinically important. The medication reconciliation process identified and addressed most of these unintended variances before harm occurred. In this small study, medication reconciliation was a useful method for identifying and rectifying medication errors at times of transition. Reconciliation warrants broader evaluation.
doi:10.1136/qshc.2005.015347
PMCID: PMC2464829  PMID: 16585113
medication reconciliation; continuity of patient care; safety management; medication errors
14.  Impact of Students Pharmacists on the Medication Reconciliation Process in High-Risk Hospitalized General Medicine Patients 
Objective. To compare the accuracy of medication lists obtained by student pharmacists, nurses, and physicians, and quantify the number of discrepancies identified as part of the medication reconciliation process.
Methods. Between May and July 2012, patients admitted to an internal medicine team at a 350-bed tertiary academic medical center were assessed for inclusion in the study. Physicians and/or nurses conducted medication reviews for these patients at the time of admission, while student pharmacists conducted medication reconciliation.
Results. Eighty-six patients were assessed, and 52 met all inclusion criteria. A total of 268 discrepancies were identified as part of the medication reconciliation performed by the student pharmacists, approximating 5 discrepancies per patient (range 0-13). Student pharmacists identified 532 preadmission medications, significantly more than did nurses (355) or physicians (368), p=0.006.
Conclusion. Student pharmacists, with appropriate oversight, can be used in several tasks that previously may have been designated to pharmacists only, such as medication reconciliation.
doi:10.5688/ajpe78234
PMCID: PMC3965142  PMID: 24672067
medication reconciliation; pharmacy; student pharmacist
15.  Medicines reconciliation on admission to inpatient psychiatric care: findings from a UK quality improvement programme 
Objective: Medication errors are a common cause of avoidable morbidity, and transfer between clinical settings is a known risk factor for such errors. Medicines reconciliation means there is no unintended discrepancy between the medication prescribed for a patient prior to admission and on admission. Our aim was to improve the quality of practice supporting medicines reconciliation at the point of admission to a psychiatric ward.
Methods: An audit-based quality improvement programme (QIP), using the proxy measure for medicines reconciliation of two or more sources of information being consulted about current medicines, and compared.
Results: At baseline audit, 42 Trusts submitted data for 1790 patients. At re-audit 16 months later, 43 Trusts submitted data for 2296 patients. While doctors were most commonly identified in Trust policies as having overall responsibility for medicines reconciliation, the task was most often undertaken by pharmacy staff, with most activity occurring within 24 h of admission. The proportion of patients in whom medicines reconciliation was possible was 71% at baseline and 79% at re-audit. In such patients, discrepancies were identified in 25% at baseline and 31% at re-audit; a small proportion of these discrepancies were clearly clinically significant.
Conclusions: This QIP achieved modest improvement in medicines reconciliation practice.
doi:10.1177/2045125311417299
PMCID: PMC3736923  PMID: 23983934
xxxx; xxxx
16.  Prevalence and Clinical Significance of Discrepancies within Three Computerized Pre-Admission Medication Lists 
Inaccurate records of pre-admission medication exposure have been identified as a major source of medication error. Authors collected records of patients’ pre-admission medications: 1) the most recent outpatient medication list (“EMR”), 2) the medication list recorded by admitting providers (“H&P”), and 3) a list generated by a medication reconciliation process conducted by nursing staff (“PAML”). Forty-eight sets of pre-admission records composed of 1087 medication entries were compared to a reference standard generated by trained study staff conducting an independent interview. Sensitivity was greatest for PAML (85%), compared to EMR (76%) and H&P (76%) sources. However, positive predictive value was greatest for the H&P source at 96% vs 88% and 91% for PAML and EMR sources respectively. Potentially harmful medication discrepancies were found within all lists. The authors concluded no single list was sufficiently accurate to avoid serious medication errors.
PMCID: PMC3041392  PMID: 21347057
17.  Classifying and Predicting Errors of Inpatient Medication Reconciliation 
Journal of General Internal Medicine  2008;23(9):1414-1422.
Background
Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur.
Objective
To determine the reasons, timing, and predictors of potentially harmful medication discrepancies.
Design
Prospective observational study.
Patients
Admitted general medical patients.
Measurements
Study pharmacists took gold-standard medication histories and compared them with medical teams’ medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs).
Results
Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs.
Conclusions
Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.
doi:10.1007/s11606-008-0687-9
PMCID: PMC2518028  PMID: 18563493
medication errors; medication systems, hospital; continuity of patient care; inpatients
18.  Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge 
Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.
doi:10.1136/amiajnl-2010-000040
PMCID: PMC3078655  PMID: 21486889
Quality improvement; patient safety; clinical decision support; hospital medicine; rascal; clinical; informatics; measuring/improving patient safety and reducing medical errors; natural-language processing; measuring/improving outcomes in specific conditions and patient subgroups; patient safety; decision support; data exchange machine learning; medication reconciliation; information systems; patient discharge
19.  Effectiveness of a Medication Reconciliation Project Conducted by PharmD Students 
Objectives
This study evaluated the effectiveness of a medication reconciliation program conducted by doctor of pharmacy (PharmD) students during an advanced pharmacy practice experience.
Methods
Patients admitted to medicine or surgery units at 3 hospitals were included. Students were instructed to interview each patient to obtain a medication history, reconcile this list with the medical chart, and identify and solve drug-related problems.
Results
Eleven students reconciled medications for 330 patients over 10 months and identified 922 discrepancies. The median number of discrepancies found per patient was 2, and no discrepancies were found in 25% of the cases. In cases in which discrepancies were identified, a greater number of medications had been prescribed for the patient (7.9 ± 4.0 medications compared to 5.4 ± 3.9 medications; p < 0.05). The students completed 59 interventions. Differences were found in the numbers of discrepancies and drug-related problems that different students at different sites identified (p < 0.05).
Conclusions
Pharmacy students provided a valuable service to 3 community hospitals. The students improved the quality of patient care by identifying and solving significant drug-related problems, identifying drug allergy information, and resolving home and admission medication discrepancies.
PMCID: PMC2064892  PMID: 17998991
medication reconciliation; advanced pharmacy practice experience
20.  Enhance the Accuracy of Medication Histories for the Elderly by Using an Electronic Medication Checklist 
Medication errors may result in serious safety issues for patients. Medication error issues are more prevalent among elderly patients, who take more medications and have prescriptions that change frequently. The challenge of obtaining accurate medication histories for the elderly at the time of hospital admission creates the potential for medication errors starting at admission.
A study at a central Texas hospital was conducted to assess whether an electronic medication checklist can enhance the accuracy of medication histories for the elderly. The empirical outcome demonstrated that medication errors were significantly reduced by using an electronic medication checklist at the time of admission. The findings of this study suggest that implementing electronic health record systems with decision support for identifying inaccurate doses and frequencies of prescribed medicines will increase the accuracy of patients’ medication histories.
PMCID: PMC3510644  PMID: 23209450
electronic medication checklist; medication history; adverse drug events (ADEs); admission interview; the elderly; medication errors; electronic health record
21.  Design and Implementation of a Medication Reconciliation Kiosk: the Automated Patient History Intake Device (APHID) 
Errors associated with medication documentation account for a substantial fraction of preventable medical errors. Hence, the Joint Commission has called for the adoption of reconciliation strategies at all United States healthcare institutions. Although studies suggest that reconciliation tools can reduce errors, it remains unclear how best to implement systems and processes that are reliable and sensitive to clinical workflow. The authors designed a primary care process that supported reconciliation without compromising clinic efficiency. This manuscript describes the design and implementation of Automated Patient History Intake Device (APHID): ambulatory check-in kiosks that allow patients to review the names, dosage, frequency, and pictures of their medications before their appointment. Medication lists are retrieved from the electronic health record and patient updates are captured and reviewed by providers during the clinic session. Results from the roll-in phase indicate the device is easy for patients to use and integrates well with clinic workflow.
doi:10.1197/jamia.M2642
PMCID: PMC2732234  PMID: 19261949
22.  Accuracy of the medication history at admission to hospital in Saudi Arabia 
Objective
Inaccurate medication history at admission to hospitals leads to preventable adverse drug events, which in turn increase mortality, morbidity, and health care costs. The objective of this study was to investigate the role of pharmacists in identifying discrepancies in medication histories at admission to a tertiary referral hospital in Saudi Arabia.
Methods
We performed a prospective observational study in a 1200 bed tertiary hospital in Riyadh, Saudi Arabia. Patients were included if they were aged 16 years or older, were taking 5 or more medications, and were able to communicate or were accompanied by a caregiver who could communicate. Over 2 months in 2009, a pharmacist interviewed patients to ascertain all medications used prior to hospitalization, then all discrepancies were discussed with the admitting physician and unintended discrepancies were reported as errors.
Results
A pharmacist interviewed 60 patients who were taking 564 medications total. Of these patients, 65% were male, and their mean age was 62. Patients were taking an average of 9.4 medications. Twenty-two (37%) patients had at least one discrepancy, with the most common being omissions of medications (35%) and dosage errors (35%). The mean age for patients with discrepancies was 64.6 years, and without discrepancies, 60.8 years (P = 0.37).
Conclusion
Inaccurate medication history at admission to a hospital was common in Saudi Arabia. This has the potential to cause harm to patients if it remains undetected. Pharmacists could potentially play a major role in obtaining this medication history at the time of hospital admission.
doi:10.1016/j.jsps.2011.04.006
PMCID: PMC3745046  PMID: 23960767
Medication errors; Transitions; Discrepancies
23.  Student pharmacist initiated medication reconciliation in the outpatient setting 
Pharmacy Practice  2012;10(2):78-82.
The Joint Commission continues to emphasize the importance of medication reconciliation in all practice settings. Pharmacists and student pharmacists are uniquely trained in this aspect of patient care, and can assist with keeping accurate and complete medication records through patient interview in the outpatient setting.
Objective
The objective of this study was to quantify and describe medication reconciliation efforts by student pharmacists in an outpatient family medicine center.
Methods
A retrospective review was conducted of all standard medication reconciliation forms completed by student pharmacists during patient interviews from April 2010 to July 2010. The number of reviews conducted was recorded, along with the frequency of each type of discrepancy. A discrepancy was defined as any lack of agreement between the medication list in the electronic health record (EHR) and the patient-reported regimen and included any differences in dose or frequency of a medication, duplication of the same medication, medication no longer taken or omission of any medication.
Results
A total of 213 standard medication forms from the 4 month period were reviewed. A total of 555 discrepancies were found, including medications no longer taken, prescription medications that needed to be added to the EHR, over-the-counter(OTC) and herbal medications that needed to be added to the EHR, medications taken differently than recorded in the EHR, and medication allergies which needed to be updated. An average of 2.6 discrepancies was found per patient interviewed.
Conclusions
Student pharmacist-initiated medication reconciliation in an outpatient family medicine center resulted in the resolution of numerous discrepancies in the medication lists of individual patients. Pharmacists and student pharmacists are uniquely trained in medication history taking and play a vital role in medication reconciliation in the outpatient setting.
PMCID: PMC3780482  PMID: 24155821
Medication Reconciliation; Continuity of Patient Care; Electronic Health Records; Students, Pharmacy; United States
24.  Completeness of Information Sources Used to Prepare Best Possible Medication Histories for Pediatric Patients 
Background:
Medication reconciliation can reduce medication errors and mortality. With limited availability of clinical pharmacists, it is important to determine the resources that will yield the most complete information about a patient’s medication history.
Objective:
To identify the most time-efficient sources of information about medication history for use by clinicians in a pediatric care setting.
Methods:
In July and August 2009, newly admitted pediatric patients (under 18 years of age) were identified, and a best possible medication history (BPMH) was compiled from the admission history in each patient’s chart, a provincial prescription database, a community pharmacy record, and an “informed interview”. Each individual source of information was compared with the BPMH and given a completeness score based on 3 pieces of information about each medication (name, dose, and frequency).
Results:
Data were collected for 99 pediatric patients. Of these, 76 (77%) were taking at least one medication, and 49 (50%) were taking at least one prescription medication. Among patients who were taking at least one medication, the informed interview, based on background information from other sources, resulted in the most comprehensive medication history, with a median completeness score of 100% (interquartile range [IQR] 90% to 100%). The admission history had a median completeness score of 33% (IQR 4% to 56%), with documentation of dose and frequency lacking most frequently. Information from community pharmacies had a median completeness score of 67% (IQR 42% to 87%), but this source was available for only 24 of the 99 patients. The prescription database was the least complete source, with a median completeness score of 0% (IQR 0% to 37%).
Conclusion:
An informed interview by a trained professional resulted in the most complete medication history. Admission histories represented the next most complete source. The data from this study indicated a need for education on the performance of medication reconciliation that would emphasize the use of all available background information, documentation of dose and frequency for each medication, and inclusion of both over-the-counter and herbal products.
PMCID: PMC3053187  PMID: 22479023
pediatrics; medication reconciliation; adverse drug events; best possible medication history; pédiatrie; bilan comparatif des médicaments; événements indésirables liés aux médicaments; meilleur schéma thérapeutique possible
25.  Impact of Electronic Medication Reconciliation at Hospital Admission on Clinician Workflow 
Many hospitals have experienced challenges with accomplishing the Joint Commission’s National Patient Safety Goal for medication reconciliation. Our institution implemented a fully electronic process for performing and documenting medication reconciliation at hospital admission. The process used a commercial EHR and relied on a longitudinal medication list called the “Outpatient Medication Profile” (OMP). Clinician compliance with documenting medication reconciliation was difficult to achieve, but approached 100% after a “hard-stop” reminder was implemented. We evaluated the impact of the process at a large urban academic medical center. Before the new process was adopted, the average number of medications contained in the OMP for a patient upon admission was <2. One year after adoption, the average number had increased to 4.7, and there were regular updates made to the list. Updating the OMP was predominantly done by physicians, NPs, and PAs (94%), followed by nurses (5%) and pharmacists (1%).
PMCID: PMC3041362  PMID: 21347093

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