Impact of Pharmacist-Directed Medication Reconciliation in Reducing Medication Discrepancies: A Randomized Controlled Trial

Background: In hospital surgical wards, patients are at higher risk for medication errors, in part because physicians may not consider themselves sufficiently trained to prescribe medications. Hence, collaborative teamwork involving the pharmacist is needed. Objectives: To assess the impact of medication reconciliation directed by pharmacists on decreasing medication discrepancies after discharge from the surgical ward. Methods: Patients admitted to the surgical unit at a tertiary teaching hospital in Amman, Jordan, between July 2017 and July 2018 were selected and randomly assigned to either the control or the intervention group. Upon admission, the number and kinds of unintentional medication discrepancies were determined for both groups. Medication reconciliation was then provided to patients in the intervention group. The number of unintentional discrepancies was re-evaluated upon discharge for both groups. To assess differences between the control and intervention groups, the c(2) or Fisher exact test was used for categorical variables and an independent-sample t test for continuous data. A paired t test was conducted to determine whether the number of medication discrepancies was reduced as a result of pharmacists' recommendations. Results: A total of 123 patients met the inclusion criteria, 61 in the intervention group and 62 in the control group. Discrepancies of omission and wrong dose constituted 41 (77%) of the 53 discrepancies in the intervention group and 25 (76%) of the 33 discrepancies in the control group. The number of unintentional discrepancies was significantly reduced from admission to discharge in both the intervention group (p = 0.002) and the control group (p = 0.007). Of 53 recommendations made by pharmacists, 20 (38%) were accepted by the treating physician, and all of these discrepancies were resolved. Conclusions: This study sheds light on the existence of unintentional medication discrepancies upon admission for surgical patients, which may expose the patients to potential harm upon discharge from hospital. Additional studies with a larger sample size are needed to gain further insights on pharmacists' role in implementing medication reconciliation for surgical patients.