Impact of Pharmacy-Driven Medication Reconciliation upon Admission to Improve Patient Safety in a Family Medicine Unit

Introduction: Medication reconciliation is the process of comparing a patient’s ordered medications to what the patient is actually taking. For several years, it has been included as part of The Joint Commission National Patient Safety Goals for improving medication safety.  Our study investigated the impact of pharmacy personnel involvement in the medication reconciliation process on a family medicine unit in a large, urban, academic medical center. Materials and Methods: A prospective, non-randomized, cross-sectional study was conducted from November 2017 through March 2018. The number of medication discrepancies identified as well as the characteristics of the patients, types and medication classes most commonly associated with discrepancies were assessed. Results: Approximately 104 out of 134 or 78% of patients had at least one discrepancy at the time of admission. The most common discrepancy type was related to the electronic medical record followed by omissions, patient non-compliance and the drug being held.  The medication classes mostly commonly associated with discrepancies were over the counter medications, cardiac medications and analgesics. Of the 104 patients that had at least one discrepancy, 31 (30%) required an intervention by a member of the pharmacy team. Conclusion: Pharmacy interns identified additional prescription and non-prescription medication discrepancies after the medication reconciliation process had already been completed. Involving pharmacy interns in a formal, standardized medication reconciliation process can help maintain and communicate accurate patient information.