Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Background Medication reconciliation has been mandated by the Irish government at transfer of care. Research is needed to determine the contribution of clinical pharmacists to the process. Objective To describe the contribution of emergency department based clinical pharmacists to admission medication reconciliation in Ireland. Main Outcome Measure Frequency of clinical pharmacist’s activities. Setting Two public university teaching hospitals. Methodology Adults admitted via the accident and emergency department, from a non-acute setting, reporting the use of at least three regular prescription medications, were eligible for inclusion. Medication reconciliation was provided by clinical pharmacists to randomly-selected patients within 24-hours of admission. This process includes collecting a gold-standard pre-admission medication list, checking this against the admission prescription and communicating any changes. A discrepancy was defined as any difference between the gold-standard pre-admission medication list and the admission prescription. Discrepancies were communicated to the clinician in the patient’s healthcare record. Potentially harmful discrepancies were also communicated verbally. Pharmacist activities and unintentional discrepancies, both resolved and unresolved at 48-hours were measured. Unresolved discrepancies were confirmed verbally by the team as intentional or unintentional. A reliable and validated tool was used to assess clinical significance by medical consultants, clinical pharmacists, community pharmacists and general practitioners. Results In total, 134 patients, involving 1,556 medications, were included in the survey. Over 97 % of patients (involving 59 % of medications) experienced a medication change on admission. Over 90 % of patients (involving 29 % of medications) warranted clinical pharmacy input to determine whether such changes were intentional or unintentional. There were 447 interventions by the clinical pharmacist regarding apparently unintentional discrepancies, a mean of 3.3 per patient. In total, 227 (50 %) interventions were accepted and discrepancies resolved. At 48-hours under half (46 %) of patients remained affected by an unintentional unresolved discrepancy (60 % related to omissions). Verbally communicated discrepancies were more likely to be resolved than those not communicated verbally (Chi-square (1) = 30.029 p < 0.05). Under half of unintentional unresolved discrepancies (46 %) had the potential to cause minor harm compared to 70 % of the resolved unintentional discrepancies. None had the potential to result in severe harm. Conclusion Clinical pharmacists contribute positively to admission medication reconciliation and should be engaged to deliver this service in Ireland.
- Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414–22. CrossRef
- Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424–9. CrossRef
- Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Car. 2006;15:122–6. CrossRef
- Rees S, Thomas P, Shetty A, Makinde K. Drug history errors in the acute medical assessment unit quantified by use of the NPSA classification. Pharm J. 2007;279:469–71.
- Wong JD, Bajcar JM, Wong GG, Alibhai SMH, Huh J-H, Cesta A, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42:1373–9. CrossRef
- Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510–5. CrossRef
- Grimes TC, Duggan CA, Delaney TP, Graham IM, Conlon KC, et al. Medication details documented on hospital discharge: cross sectional observational study of factors associated with medication non-reconciliation. Br J Clin Pharmacol. 2011;71(3):449–57. CrossRef
- Fitzsimons M, Grimes T, Galvin M. Sources of pre-admission medication information: observational study of accuracy and availability. Int J Pharm Pract. 2011;19(6):408–16. CrossRef
- Institute for Healthcare Improvement. Accuracy at every step: the challenge of medication reconciliation. Cambridge: Institute of Healthcare Improvement; 2006.
- Madden D. Building a culture of patient safety. Report of the commission on patient safety and quality assurance (IE). Department of Health, Ireland; 2008.
- National Institute for Health and Clinical Excellence/National Patient Safety Agency. Technical patient safety solutions for medicines reconciliation on admission of adults to hospitals. PSG001; 2007.
- National Prescribing Centre (UK). Medicines reconciliation: a guide to implementation. Good practice guide, 5 min guides; 2008.
- Campbell F, Karnon J, Czoski C, Jones R. A systematic review of the effectiveness and cost-effectiveness of interventions aimed at preventing medication errors (medicines reconciliation) at hospital admission. The University of Sheffield, School of Health and Related Research. (ScHARR); 2007.
- de Winter S, Spriet R, Indevuyst C, Vanbrabant P, Desruelles D, Sabbe M, et al. Pharmacist-versus-physician-acquired medication history: a prospective study at the emergency department. Qual Saf Health Care. 2010;19(5):371–5. CrossRef
- Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health Syst Pharm. 2002;59:2221–5.
- Karnon J, Campbell F, Czoski C. Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation). J Eval Clin Pract. 2009;15:299–306. CrossRef
- Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomised controlled trial. Arch Intern Med. 2009;169:894–900. CrossRef
- Burnett KM, Scott M, Fleming GF, Clark CM, McElnay JC. Effects of an integrated medicines management program on medication appropriateness in hospitalised patients. Am J Health Syst Pharm. 2009;66:854–9. CrossRef
- Scullin C, Scott MG, Hogg A, et al. An innovative approach to integrated medicines management. J Eval Clin Pract. 2007;13:781–8. CrossRef
- Karapinar-Carkit F, Borgsteede S, Zoer J, et al. Effect of medication reconciliation with and without patient counselling on the number of pharmaceutical interventions among patients discharged from the hospital. Ann Pharmacother. 2009;43:1001–10. CrossRef
- Royal College of Physicians of Ireland/Irish Association of Directors of Nursing and Midwifery/Therapy Professions Committee/Quality and Clinical Care Directorate, Health Service Executive. Report of the National Acute Medicine Programme 2010 (internet) accessed 5th October 2011 http://www.hse.ie/eng/services/Publications/services/Hospitals/AMP.pdf.
- Bolas H, Brookes K, Scott M, et al. Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland. Pharm World Sci. 2004;26(2):114–20. CrossRef
- Bowling A. Research methods in health: investigating health and health services. 2nd ed. Buckingham: Open University Press; 2002.
- Dean BS, Barber ND. A validated reliable method of scoring the severity of medication errors. Am J Health-Syst Pharm. 1999;56:57–62.
- Vasileff HM, Whitten LE, Pink JA, et al. The effect on medication errors of pharmacists charting medication in an emergency department. Pharm World Sci. 2009;31:373–9. CrossRef
- Cohen V, Jellinek SP, Hatch A, Motov S. Effect of clinical pharmacists on care in the emergency department: a systematic review. Am J Health Syst Pharm. 2009;66(15):1353–61. CrossRef
- Bracey G, Miller G, Dean B, et al. The contribution of a pharmacy admissions service to patient care. Clin Med. 2008;8(1):53–7.
- Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland
International Journal of Clinical Pharmacy
Volume 35, Issue 1 , pp 14-21
- Cover Date
- Print ISSN
- Online ISSN
- Springer Netherlands
- Additional Links
- Clinical pharmacy
- Hospital pharmacy
- Medication reconciliation
- Medication safety
- Patient safety
- Patient admission
- Industry Sectors
- Author Affiliations
- 1. Pharmacy Department, Naas General Hospital, Naas, County Kildare, Ireland
- 2. Pharmacy Department, The Adelaide Hospital and Meath, Incorporating the National Children’s Hospital, Dublin, 24, Ireland
- 3. School of Pharmacy, Trinity College Dublin, Dublin, 2, Ireland