Photo Credit: Aree Sarak

Pharmacist-led medication reconciliation, implemented prior to a patient’s admittance to the hospital for surgery, improved safety and outcomes.

Studies have shown that medical errors involving prescriptions in the hospital setting often stem from medical history obtained at admission. Causes include missing information and discrepancies in the patient’s medication history. Many of these studies examined post-admission-led medication reconciliation (MR) by pharmacists; however, little, if any, information is available on the impact of pre-admission pharmacist intervention in MR.

To explore this further, Ryo Kobayashi, PhD, and colleagues developed a retrospective observational study focused on a single healthcare center. They published their findings in the Journal of Pharmaceutical Health Care and Sciences.

Pre- and Post-Initiation Compared

The study took place in the orthopedic ward of Gifu University Hospital. A total of 2,690 patients were included in the study. These patient participants were then separated into two cohorts—pre-initiation of intervention and post-initiation of intervention. The patients in the pre-initiation group (n=1041) did not receive pharmacist MR intervention before pre-admission to the hospital, and the post-initiation group (n=1,649) received pharmacist MR intervention before pre-admission to the hospital. The median period between pharmacist-led MR and hospital admission in the post-initiation group was 13 days. The study participants’ age and male/female ratio were similar within the two groups.

Communication

Within the post-initiation cohort, 306 patients taking antithrombotic medicine before they were admitted to the hospital needed to pause their antithrombotic regimen due to scheduled surgical procedures. Of these patients, 69.9% had the pharmacist concur with the patient’s overseeing physician that the withdrawal instructions were appropriate. In 30.1% of the patients in this antithrombotic medicine-taking group, the pharmacist recommended to the overseeing physician that the patient’s antithrombotic medication be suspended. In 95.7% of these cases, the physician accepted the recommendation.

In the pre-initiation group, 76% of patients were taking medication before admission to the hospital, and in the post-initiation group, 80.1% were. In the pre-initiation group, 1.0% of patients already taking medication were instructed by their physicians to continue the medications that were prescribed to them before hospitalization compared to the post-initiation group, in which 47.4% of patients were instructed by physicians to continue the medications that were prescribed to them before hospitalization (P<0.001).

Medication Errors

Medication errors related to pre-admission medication actions in the post-initiation group were 0.85% compared to the pre-initiation group, which was 1.83% (P=0.025). Excluding patients who did not have a medication regimen at pre-admission, medication errors in the post-initiation group were 1.06% compared with 2.38% in the pre-initiation group (P=0.018). The causes of the medication errors were errors by a healthcare professional, dose omission, overdose, administration of the wrong drug, loss of drugs, administration to the incorrect patient, and patient error. The researchers noted that none of these medication errors severely affected patient outcomes.

When multivariate analysis was applied to the data gathered, it was found that pharmacist-led MR that occurred before a patient was admitted to the hospital provided significant protection against factors contributing to medication error during the pre-admission process (OR, 0.3810; 95% CI, 0.156–0.9320; P=0.035).