Discharge transitions in care represent a high‐risk period for medication errors and adverse drug events such as medication discrepancies. Although there is literature on improving admission medication reconciliation (Cornish et al. Arch Mem Med. 2005;165:424‐429). Ihere is less current evidence on the process at discharge. The use of inpatient clinical pharmacists is increasingly prevalent, and there is growing literature on their role as part of a team with hospitalists (Varkey et al., Am J Heattft‐Syst Pharm. 2007;64:850‐854). We have had a decentralized pharmacist model for many years, primarily relying on them for order verification and medication distribution. Clinicians consult this pharmacist as needed, but do not include them in daily rounds. We piloted a new team‐based pharmacist model as part of Project BOOST (Better Outcomes for Older Adults through Safe Transitions), a SHM transitions‐in‐care initiative, in order to attempt lo improve discharge medication safety.
To implement and evaluate a new discharge medication reconciliation process involving hospitalisl teams, nurses, and pharmacists.
A discharge medication reconciliation process was initiated on our nonleaching hospitalist service as a part of Project BOOST. An internal medicine clinical pharmacy specialist rounded at bedside daily with the attending physician and nurse‐practitioners. This involvement was prioritized to help the pharmacist gain insights into clinical, social, and other factors to optimize inpatient medication therapy. The pharmacist was then selectively consulted on the day of discharge for medication reconciliation on patients who were believed to be al high risk for medicalion‐related issues. The pharmacist reviewed patient discharge instructions, and prescriptions and medication discrepancies were discussed with the primary inpatient provider. Unintentional medication discrepancies were resolved prior to discharge and recorded in a database. Over a 10‐month period, 354 patients had pharmacist medication reconciliation. Thirty‐seven percent of these patients had unintentional discrepancies uncovered by the pharmacist, an average of 1.5 per patient. There were 201 pharmacist‐driven interventions. The most common was preventing incorrect dose on discharge (n = 87.45%). Figure 1 shows a breakdown of other errors identified and intervened on by pharmacist discharge medication reconciliation
Pharmacist‐d riven discharge medication reconciliation improved the quality and accuracy of discharge prescriptions and patient discharge instructions. More significantly, a number of potentially harmful drug‐related complications were averted. We hope to expand this model to other units, either by recruiting more residency‐trained clinical pharmacists or by utilizing the decentralized pharmacists in a team‐based, bedside‐rounding model.
J, Ocampo, Hospital of The University of Pennsylvania Department of Pharmacy, employee/none; E, King. University of Pennsylvania School of Medicine. Department of Medicine, faculty/none.
To cite this abstract:Ocampo J, King E. Pharmacist‐Driven Discharge Medication Reconciliation as Part of Project BOOST. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 183. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/pharmacistdriven-discharge-medication-reconciliation-as-part-of-project-boost/. Accessed July 24, 2019.