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Improving Patient Safety through Implementation of a Pharmacist-Conducted Admission Medication History and Discharge Medication Reconciliation Process

Eileen M. Murphy, Pharm.D.; Carolyn J. Johnston, Pharm.D.; James A. Klauck M.S., R.Ph.; Douglas A. Meyer M.B.A., R.Ph.; Cynthia R. Hennen B.S., R.Ph.; Kristin K. Hanson M.S., R.Ph.; Michael Sura, Pharm.D. (Acknowledgements: Jill Zimmerman, M.S., Pharm.D.; Chris Schuenke, Pharm.D., CGP


Froedtert Hospital, Milwaukee, Wisconsin

The purpose of the program was to design and implement a comprehensive medication reconciliation program that would improve the accuracy of the admission medication history process and reduce errors in both admission and discharge medication orders.

In March 2005, a pharmacist conducted medication history and admission reconciliation pilot was completed. A total of 101 discrepancies were identified between the admission orders and home medication regimens during 53 patient interviews. As a result, in November 2005, pharmacists began to conduct admission medication histories on all inpatients, and 3.5 pharmacist full-time equivalents (FTEs) were added based on time estimations determined in the pilot. In late 2006, after policies and procedures for admission reconciliation were in place and the process was functioning well, the focus shifted to discharge medication reconciliation. A baseline assessment was completed on 148 patient discharges.  The two most common physician discharge errors were omission of home and inpatient-initiated medications. In order to improve the discharge ordering process, a computer-generated report was created to capture patients’ home and inpatient-initiated medications and order medications for discharge.  Discharge orders were then entered back into the clinical information system by pharmacy. In June 2007, this discharge reconciliation report form was implemented hospital-wide. Six FTEs were added to the pharmacy department to support the additional workload required for pharmacist verification of discharge orders.

In 2006, an analysis of the pharmacist driven admission reconciliation process was completed. A total of 163 discrepancies were discovered when comparing physician admission orders to pharmacist-obtained home medication lists, averaging 1.8 discrepancies per patient. Omission of a home medication was the most common discrepancy. Pharmacist interventionwas necessary to resolve discrepancies in 53% of patients. After separation of intentional versus unintentional discrepancies, the number of unintentional discrepancies fell to 0.7 per patient.  Analysis of the new discharge reconciliation process was conducted by auditing discharges after implementation of the discharge medication reconciliation form. Discharge orders were manually reviewed on the medicine (63 discharges) and surgical (49 discharges) units. Omitted home medications were reduced from 21% to 0% of orders on the surgical unit and from 11% to 0% of orders on the medicine unit. Omitted inpatient medications were reduced from 8% to 1% on the surgical unit and from 11% to 0% on the medicine units. Statistically significant reductions were seen in omitted or incorrect strength, omitted or incorrect directions, and unacceptable abbreviations. Overall, implementation of a computer-generated discharge medication report reduced the average number of prescribing errors per discharge from 4.7 to 2.2 on the surgical unit and from 4.9 to 1.6 on the medicine unit.

Pharmacist-conducted admission medication histories provide an accurate medication list from which reconciliation is possible. Use of a computer-generated discharge order form containing a comprehensive medication list that has been reviewed by pharmacists eliminates a transcription step and reduces errors in discharge orders. Pharmacist involvement in both admission and discharge reconciliation significantly reduces the potential for medication errors and improves patient safety.

View a pdf of the poster from the Midyear Meeting (2.5MB).