Improving medicine information on discharge summaries through implementation of a reconciliation-based intervention

The handover of medication-related information at the point of discharge often occurs via the discharge summary (DS), although these frequently contain errors. We aimed to investigate whether an intern pharmacist reviewing the medication details in discharge summaries (DSs), reconciling them with the discharge prescription and pointing out any discrepancies with the medical staff would reduce the rate of medication errors. The intervention was retrospectively reviewed by comparing medication information on the DS with the discharge prescription (considered the 'source of truth'). Error rates on the DS were compared to a control group of patients discharged over a different 2-week period from the same ward. A modified APINCH (Antimicrobials, Potassium and other electrolytes, Insulin, Narcotics and other sedatives, Chemotherapeutic agents, Heparin and other anticoagulants, Systems) classification system was used to identify high-risk errors. The time taken to perform the intervention was measured and details of any recommendations collected. The study included 22 intervention patients and 31 control patients. Patients who received the intervention were less likely to have one or more medication errors on their DS (any: 4% vs 84%, p < 0.01; high-risk: 0% vs 29%, p < 0.01). The intern pharmacist made a total of 77 recommendations during the intervention. Six recommendations (8%) related to high-risk medications. The median time required to undertake the first review was 4 min, and the second review took 1 min. In conclusion, we found a reconciliation-based intervention involving an intern pharmacist could reduce the rate of medication errors on DSs.