The implementation of pharmacist driven medication reconciliation program at the admission to hospital

Objective: The aim of the study was to evaluate pharmacist driven medication reconciliation program at the admission to hospital. Method: This study was conducted between February 13, 2012 and April 29, 2012 (two days in a week) at internal medicine and oncology service of a private hospital located in Istanbul, Turkey. Patients were eligible if they were older than 18 years old and if the medication reconciliation form was compiled within 48 hours of admission. The pharmacists reviewed if there were any discrepancies between a patient's home medication and medications prescribed on admission to the hospital. When the discrepancies were found, the pharmacists investigated further whether if this discrepancy was intentional or unintentional by communicating with patient, patient caregiver, the physician or by checking patient's pharmacy record. Potentially high-risk admission discrepancies were also identified. The discrepancies were classified as omission, duplication, and name/dose/route confusion. Results: Fifty four patients (mean age, 61.07 +/- 15.21 years; 26 female/28 male) were included in the study. Twenty three patients were older than 65 years The overall rate of recently started medications at admission to hospital was 6.4 per patient. Forty seven patients utilized at least one high-risk medication. In admission to hospital, at least one medication was intentionally or unintentionally discontinued in 35 patients. In medication reconciliation process, the total of 23 unintended discrepancies were determined among 12 patients. The overall rate of unintended discrepancies was 0.43 per patient. The most common unintended discrepancies were name/dose/route confusion (n=12) and omission of regularly used medication (n=9). 91.70% of the patients with unintended discrepancy utilized at least one high-risk medication. Conclusion: This study showed that the pharmacist driven medication reconciliation program would provide benefit on decreasing medication related problems during admission to hospital and needs to be implemented.