Pharmacist Facilitated Discharge: A Prospective Study of Medication Discrepancies

1University of Michigan, Ann Arbor, MI

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 80


Medical patients frequently experience medication changes during hospitalization. This increases the risk of medication‐related errors at discharge that may cause adverse events, resulting in increased mortality, readmission, and costs. As a result, the Joint Commission on Accreditation of Healthcare Organizations now requires medication reconciliation at discharge to prevent errors. We prospectively studied the impact of a pharmacist‐facilitated discharge program on identifying medication discrepancies at discharge and compared discrepancies on a nonresident faculty hospitalist service with those on a traditional resident service.


Over a 10‐month period, a clinical pharmacist alternated monthly between a nonresident faculty hospitalist service (FH) and a traditional resident service (RS). The pharmacist screened patients meeting the following inclusion criteria: discharged home, prescribed more than 5 medications with at least 1 high‐risk medicine, English speaking, and having active telephone service. During weekdays the pharmacist identified and communicated discrepancies to clinicians, counseled patients and families, and contacted patients by phone within 72 hours of discharge and again after 30 days to identify and address medication‐related problems.


A total of 1122 patients were discharged home from both services, of whom 958 were assessed. Of those assessed, 76% (358/469) on the FH and 74% (363/489) on the RS met inclusion criteria. Only 135 of the eligible patients on the FH (38%) and 113 of those eligible on the RS (31%) were able to be counseled at discharge. Time constraints and uncommunicative patients were the most common reasons for failure to counsel. Medication discrepancies occurred less often on the FH than on the RS (58%[78/135] vs. 70% [79/113], respectively, P = .048), with an average of 2.9 per patient on the FH and 3.3 per patient on the RS. Of all discrepancies, missing medications (41% [200/486]), failure to discontinue a medicine (24% [115/486]), and wrong dose/frequency (16% [79/486]) were the most common. Failure to discontinue a medication occurred more often on the RS than on the FH. Follow‐up phone calls within 72 hours and after 30 days were completed to 73 (29%) and 29 (12%), respectively, of the patients counseled at discharge. A total of 145 problems were identified and resolved by the clinical pharmacist after discharge.


At a major academic medical center, medication discrepancies as identified by a clinical pharmacist were disturbingly common but occurred less frequently on a faculty hospitalist than on a traditional resident service. Even when discrepancies were resolved at discharge, follow‐up phone calls identified frequent medication problems. A clinical pharmacist was able to identify and resolve most discharge medication issues. The impact of a clinical pharmacist on mortality, readmissions, and overall costs warrants further investigation.

Author Disclosure:

S. A. Flanders, None; P. C. Walker, None; J. Tucker‐Jones, None; J. Piersma, None; S. J. Bernstein, None.

To cite this abstract:

Flanders S, Walker P, Tucker‐Jones J, Piersma J, Bernstein S. Pharmacist Facilitated Discharge: A Prospective Study of Medication Discrepancies. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 80. Journal of Hospital Medicine. 2007; 2 (suppl 2). Accessed March 28, 2020.

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