Medication Reconciliation
Sonya Collins
WHO has noted that, upon hospital discharge, as many as 80% of patients may have a medication discrepancy or a health care provider may have failed to communicate an in-hospital medication change. These discrepancies can lead to increased health care costs, hospital readmissions, and patient harm.
Conversely, at a very low cost to health systems, pharmacist-led medication reconciliation for patients upon hospital discharge could prevent patient harm, reduce costs related to unnecessary health encounters, and stop errors from persisting across transitions of care, according to a study published June 4, 2024, in the Journal of the American College of Clinical Pharmacy.
“This study just adds to the evidence that pharmacists provide high-value, high-impact interventions that optimize patient care,” said Tiffany Pon, PharmD, a professor of clinical pharmacy at the University of California San Francisco School of Pharmacy and coauthor of the study.
Preventing patient harm
Patients discharged from adult internal medicine service at UC Davis Health in October 2022 were included in the study. Upon discharge, the pharmacist, who had been on the care team throughout the patient’s hospitalization, reviewed the patient’s medication list to identify errors or any necessary changes. The pharmacist then worked with the physician to correct the errors and make the necessary changes.
“Our patient population usually has quite a long list of medications,” said Linda Zheng, PharmD, study coauthor. “That long list complicates things, and people make mistakes.
When you have a lot of changes during a patient’s stay, it’s easy to miss things. That’s why we thought it would help if we took a second look.” Zheng, who was a pharmacy resident at UC Davis when the study was conducted, is the inpatient supervisor at Kaiser Permanente Antioch Medical Center.
The pharmacist’s second look helped significantly, the study found.
Pharmacist-led discharge medication reconciliation uncovered 40 errors in the medications of the 31 patients included in the prospective pilot study. Twenty-one patients had at least one error. The most common errors, each making up 25% of the total errors respectively, were duplication of therapy and medication access barriers.
Among some of the common access barriers were prescriptions that were not covered by the patient’s insurance; lack of access to necessary equipment, such as diabetes supplies; and inadequate infrastructure needed to use a particular medication, such as stable housing with refrigeration for insulin.
During the pilot study, researchers ranked errors by severity, with 22.5% graded as low, 75% as serious, and 2.5% as life-threatening.
“We hypothesized what might have happened without our intervention if the error hadn’t been caught and had reached the patient,” Zheng explained. “Errors that would have required an emergency visit or readmission, for example, were classified as serious.”
Thirty-five percent of the errors could have led to emergency visits or readmission, the study found.
Excellent cost:benefit ratio
The study authors estimated that the total cost of the errors, had they reached the patients, would have been $25,600. This included a projected $24,784 in costs from 14 errors that could have resulted in additional emergency visits or hospital admissions.
While the clinical service has the potential to save patients and payers a great deal of money, it does not cost a lot to administer. The cost of the pharmacist’s labor during the one-month pilot was $816.
“We demonstrated that we are able to catch those errors, in a short amount of time, and without putting excessive work into it,” Zheng said. “The benefits outweigh the cost, so there’s no reason not to do it.” ■