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Impact of Pharmacy-led Medication Reconciliation on Medication Discrepancies in Patients Admitted to


Medication Reconciliation (MedRec) is a formal process where healthcare professionals partner with patients, families, and care providers, to obtain an accurate and complete list of prescribed and over-the-counter medications a patient is currently taking (“Medication Reconciliation (MedRec),” 2020). This list, ideally completed when the patient is admitted to hospital, is used during transitions of care (i.e., admission, transfer, and discharge) to reduce medication errors. The first step involves “creating the most accurate list possible of medications a patient is taking [at home]” (“Medication Reconciliation to Prevent Adverse Drug Events,” 2020) – known as the best possible medication history (BPMH). This entails interviewing the patient or family about their medications, and confirming the information with at least one other reliable source (e.g., patient’s community pharmacy). The second step involves using the BPMH during transitions of care to “ensure that medications being added, changed, or discontinued are carefully evaluated” (“Medication Reconciliation (MedRec),” 2020) by the prescriber to avoid medication discrepancies. Common discrepancies include “inadvertent omission of needed home medications, failure to restart home medications following transfer or discharge, duplicate therapy…, and incorrect doses” (“Medication Reconciliation (MedRec),” 2019). MedRec has been recognized as such a vital part to preventing adverse drug events, that Accreditation Canada classifies MedRec as a required organizational practice (ROP) (“Required Organizational Practices (ROPs),” 2020). While MedRec is recognized as having an important role in patient safety, successful implementation has been difficult to achieve in hospitals. Sequeria and colleagues (2017) reported that only an average of 60% of patients received MedRec on admission in 2017/18 across Ontario. The main barriers to success include how time-consuming the MedRec process is, and the difficulties in obtaining an accurate medication history from patients (Chevalier, Parker, MacKinnon, & Sketris, 2006).

Equipped with medication expertise, a pharmacy-led model of MedRec may possess strategic advantages to quickly and accurately identify a patient’s home medications. For example, my experience has shown that pharmacists and pharmacy technicians are more often able to identify a medication based on colour, shape, pill markings, and frequency of administration.

This is extremely helpful as patients often report their medications by using one or more of these descriptions. The pharmacy team also has an established relationship with nearby community pharmacies, which may allow for more efficient transfer of medication information. The following CAT evaluates the impact of a pharmacy-led model of MedRec on medication discrepancies among patients who are admitted to acute care hospitals.

What is the impact of a pharmacy-led model of MedRec in comparison to usual care on medication discrepancies among patients who are admitted to acute care hospitals?

The OVID Medline and CINAHL databases were searched, using the search terms and limits identified in the search strategy section below, to address the focused research question. Four relevant articles were identified that met the inclusion and exclusion criteria. This included one comparative study and three randomized controlled trials (RCTs). In addition, two relevant RCTs were found from a reference list review of a systematic review (SR) obtained through a Google Scholar search.

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