Impact of pharmacist-led medication reconciliation on admission using electronic medical records on accuracy of discharge prescriptions

Background Unintentional medication errors are common at hospital discharge and have the potential to cause significant patient harm. Current electronic medical records systems offer the facility to change the process of medication reconciliation by pharmacists. Aim To test the impact of pharmacist‐led medication reconciliation at admission recorded on the electronic medication form, on the timeliness and accuracy of discharge prescriptions. Method A prospective pre‐ and post‐interventional observational study was carried out from June to October 2013 at two district hospitals. Pharmacists recorded admission medication using National Medication Management Plan (phase 1) and the electronic medication form in patients’ electronic medical records (phase 2). Data collected included time taken for the medical officer to complete the medication form in electronic medical records, the number of times the medical officer was contacted by the pharmacist completing the discharge reconciliation and unintentional discharge medication discrepancy types. Results In total 118 patients were included: 66 patients in phase 1 and 52 in phase 2. Data were analysed using chi‐squared test, Fisher's exact test and Mann–Whitney test. There was a significant (33–13%, p < 0.0001) reduction in the proportion of medication orders with a discrepancy. This was because of the significant (25.5–1.9%, p < 0.0001) reduction in discrepancies relating to patients’ usual medication. Time taken for the medical officer to complete the medication form in electronic medical records decreased from 37 s/item (interquartile range, 29–48; n = 51) to 21 s/item (interquartile range, 11–35; n = 35) (p < 0.001). The number of telephone calls to medical officers decreased from 95 to 73%. Conclusion This integrated approach to medication reconciliation has highlighted patient safety benefits, and reduced medical and pharmacy workload.