Impact of pharmacist's directed medication reconciliation on reducing medication discrepancies during transition of care in hospital setting

Objectives To evaluate the effect of pharmacist's directed services (reconciliation plus counselling) on reducing medication discrepancies and improving patient's outcomes at discharge from hospital. Methods During the 3-month study period, 200 patients were randomly selected from internal medicine department from Jordan University Hospital (JUH) and allocated into two groups (intervention and control groups). The number and types of medication discrepancies were identified at admission. Then, pharmacist implemented medication reconciliation and medication counselling services to the intervention group patients. At discharge, the number of unintentional discrepancies was evaluated for both groups. Patients were assessed at 1 month following their discharge for any subsequent hospital readmissions, emergency department visits or side effects of medication therapy. Key findings The total number of identified unintentional discrepancies was 84 for the intervention group compared with 60 discrepancies for the control group. Omission and addition represented the most common types of discrepancies for both groups. Of the 84 recommendations submitted by pharmacists, clinicians accepted 78 cases (92.8%), and implemented only 46 recommendations (54.7%). At discharge, a significant reduction in the number of unintentional discrepancies was achieved for the intervention group, P-value (0.014), while no significant change was found for the control group, P-value = 0.508. One month postdischarge, a significantly higher number of patients in the control group reported experiencing side effects compared with the intervention group, P-value = 0.020. Conclusion The presence of clinical pharmacists in hospital wards had a promising effect on decreasing the number of medication errors and improving health outcomes.