Effectiveness and feasibility of pharmacist-led admission medication reconciliation for geriatric patients

Abstract

Purpose: Pharmacists have been shown to improve medication reconciliation at hospital admission. Limited resources may obligate pharmacy departments to target resources for medication reconciliation rather than extend services to the entire hospital. We conducted a prospective, randomized, nonblinded assessment of the effectiveness and feasibility of pharmacist-led admission medication reconciliation for geriatric patients.

Methods: Eighty-one geriatric patients were randomized 1:1 to receive medication reconciliation per current hospital practice or to pharmacist-led medication reconciliation at admission. The primary end point was medication profile appropriateness by pharmacist review at 48 hours postadmission. Secondary end points involved in determining the impact and feasibility of this program.

Results: Pharmacist-led medication was superior to standard hospital practice, with 48% of controls and 71% of intervention patients having appropriate medication profiles at 48 hours postadmission (P = .033). Pharmacists identified 116 discrepancies among 81 patients including predominantly omissions (41%) and a composite of wrong dose, route, or frequency (35%). Pharmacists spent a median 15 minutes per patient.

Conclusion: Pharmacists improved admission medication reconciliation for geriatric patients. Pharmacists identified a significant number of discrepancies, including predominantly omissions and wrong dose, dosage form, or frequency. Pharmacists' contributions to medication reconciliation could yield substantial benefit to patient care.