Medication Reconciliation at hospital admission and discharge: Evaluation of fidelity and process outcomes in a real-world setting

Objectives The study aimed to assess the fidelity of Medication Reconciliation (MR) delivered by the pharmacist at hospital admission and discharge, and the process outcomes. Methods Prospective study conducted in cardiology and cardiovascular surgery unit of a university hospital between September 2019 and January 2020. Independent observers collected data to measure MR fidelity, related to coverage, sources of information used to collect medication history and presence of outstanding and resolved Undocumented Discrepancies (UD). Process outcomes included medication errors and their potential to cause harm, identified by the pharmacist during the formal MR process. Results Of the eligible patients, 122 (69.7%) had their medications reconciled in a timely manner at hospital admission and 50 (43.8%) at discharge. The pharmacist consulted 2.76 (+/- 0.8) sources of information to build the medication history, on average. At least one outstanding UD was found in 101 (82.8%) patients at admission and in 41 (82.0%), at discharge. The average number of outstanding UD per patient at admission and discharge was 3.0 (+/- 2.6) and 2.4 (+/- 1.9), respectively. The UD communicated to the physician by the pharmacist during the formal MR process, involved mainly omission errors and were classified as requiring monitoring or potentially necessary intervention. In the univariate analysis, the number of drugs pre-admission and admission, the reason for admission and non-elective readmission in 30 days were associated with the presence of medication errors at admission. Conclusions This study found a high number of UD, suggesting flaws in the implementation of MR and highlight the importance of quality measurement.