title: Pharmacist medication assessments in a surgical preadmission clinic.
abstract: BACKGROUND
  In the hospital setting, postoperative admission is a key vulnerable moment when patients are at increased risk of medication discrepancies. This study measures the reduction of medication discrepancies associated with a combined intervention of structured pharmacist medication history interviews with assessments in a surgical preadmission clinic and a postoperative medication order form.
  
  
  METHODS
  In the Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) study, patients who had a preadmission clinic appointment before undergoing surgical procedures were eligible for inclusion. Patients were excluded if they were scheduled for discharge the same day as their surgery. Eligible patients were randomly assigned to the intervention arm (structured pharmacist medication history interview with assessment and generation of a postoperative medication order form) or to the standard care arm (nurse-conducted medication histories and surgeon-generated medication orders). The primary end point was the number of patients with at least 1 postoperative medication discrepancy related to home medications.
  
  
  RESULTS
  Between April 19, 2005, and June 3, 2005, a total of 464 patients were enrolled in the study, of which 227 and 237 patients were randomized to the intervention and standard care arms, respectively. In the intervention arm, 41 (20.3%) of 202 patients had at least 1 postoperative medication discrepancy related to home medications, compared with 86 (40.2%) of 214 patients in the standard care arm (P<.001). In the intervention arm, 26 (12.9%) of 202 patients had at least 1 postoperative medication discrepancy with the potential to cause possible or probable harm, compared with 64 (29.9%) of 214 patients in the standard care arm (P<.001). These were mostly omissions of reordering home medications.
  
  
  CONCLUSIONS
  A combined intervention of pharmacist medication assessments and a postoperative medication order form can reduce postoperative medication discrepancies related to home medications.
authors.affiliation: Inpatient Pharmacy Department, Toronto General Hospital, Ontario, Canada M5G 2C4.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Kwan
authors.forename: Olavo A
authors.initials: OA
authors.lastname: Fernandes
authors.forename: Jeff J
authors.initials: JJ
authors.lastname: Nagge
authors.forename: Gary G
authors.initials: GG
authors.lastname: Wong
authors.forename: Jin-Hyeun
authors.initials: JH
authors.lastname: Huh
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Hurn
authors.forename: Gregory R
authors.initials: GR
authors.lastname: Pond
authors.forename: Jana M
authors.initials: JM
authors.lastname: Bajcar
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008487:Medical History Taking / Q000379:methods*; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D009726:Nurses; D010595:Pharmacists; D011300:Preoperative Care; D012680:Sensitivity and Specificity