Background: Medication reconciliation is a technique for identifying discrepancies in drug regimens prescribed in different care settings or at different time points to inform prescribing decisions and prevent medication errors.
Objective: This study examined the effect of pharmacist-conducted medication reconciliation on the occurrence of discrepancy-related adverse drug events (ADEs) associated with drugs ordered at the time of a resident's return from the hospital to the nursing home.
Methods: This was a preintervention/postintervention study conducted in a consecutive sample of residents of a 514-bed, urban, not-for-profit nursing home who were hospitalized in its primary referral hospital, an 1171-bed academic tertiary care hospital, and returned to the nursing home between December 2002 and January 2005. In the intervention phase, a pharmacist conducted a reconciliation of drugs ordered on return to the nursing home with those received before hospitalization, and communicated prescribing discrepancies to the physician. The primary outcome was the occurrence of discrepancy-related ADEs, as ascertained by a review of the medical records performed by 2 independent physician raters.
Results: During the study period, 168 nursing home residents had 259 hospital stays. The reconciliation intervention identified 696 total prescribing discrepancies, of which physicians responded to 598 (85.9%). Among the 112 cases selected for ADE ascertainment, 11 discrepancy-related ADEs were identified, 1 in the postintervention group and 10 in the preintervention group, for an incidence of 2.3% and 14.5%, respectively (relative risk, 0.16; 95% CI, 0.02-1.2; P = NS). After adjustment for baseline ADE risk, the odds of having a discrepancy-related ADE were significantly lower in the postintervention group compared with the preintervention group (odds ratio, 0.11; 95% CI, 0.01-1.0; P = 0.05). The most commonly identified discrepancy-related ADE was pain from the omission of an analgesic (3/11 [27.3%]), and antibiotics and analgesics were the most common causes of discrepancy-related ADEs (each, 3/11 [27.3%]).
Conclusions: Pharmacist medication reconciliation and communication with the physician reduced discrepancy-related ADEs in these patients transferred between the hospital and nursing home. Studies are needed to identify the most efficient ways of carrying out this task and to adapt the reconciliation process to all care settings.