Implementation and Evaluation of a Pharmacist Driven Medication Reconciliation Service in an Academic Medical Center

Abstract

Transitions of care have been identified in the medical literature as an area in which errors are more likely to occur. Obtaining an accurate medication history is an important step when patients are admitted to a hospital and doing so can decrease preventable medication error rates. Previous studies have shown that pharmacists excel at performing medication reconciliation. With limited resources it will be more cost effective to target high risk patient populations for more intensive medication histories by pharmacy personnel. The objective of this study was to identify the quantity and type of errors corrected on a previous home medication history performed by non-pharmacy healthcare professionals as well as to recognize patients more likely to benefit from medication reconciliation. Patients admitted to the internal medicine service at OSU Medical Center were screened according to predetermined inclusion and exclusion criteria and a medication history was taken by a pharmacist. Demographic data and error rates were documented and categorized. A total of 55 patient’s home medication lists were reconciled by a pharmacist, 53 of which had already been reconciled by non-pharmacy staff. Among the 55 patients, 500 errors were identified in the group averaging 9.1 errors per patient. Error rates were highest in patients taking 11+ medications and patients from nursing homes. Pharmacist involvement in medication reconciliation can decrease preventable mediation err