title: Effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from the hospital.
abstract: BACKGROUND
  Hospital admissions are a risk factor for the occurrence of unintended medication discrepancies between drugs used before admission and after discharge. To diminish such discrepancies and improve quality of care, medication reconciliation has been developed. The exact contribution of patient counseling to the medication reconciliation process is unknown, especially not when compared with community pharmacy medication records, which are considered reliable in the Netherlands.
  
  
  OBJECTIVE
  To examine the effect of medication reconciliation with and without patient counseling among patients at the time of hospital discharge on the number and type of interventions aimed at preventing drug-related problems.
  
  
  METHODS
  A prospective observational study in a general teaching hospital was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed the interventions with and without patient counseling on discharge medications for each patient.
  
  
  RESULTS
  Two hundred sixty-two patients were included. Medication reconciliation without patient counseling was responsible for at least one intervention in 87% of patients (mean 2.7 interventions/patient). After patient counseling, at least one intervention (mean 5.3 interventions/patient) was performed in 97% of patients. After patient counseling, discharge prescriptions were frequently adjusted due to discrepancies in use or need of drug therapy. Most interventions led to the start of medication due to omission and dose changes due to incorrect dosages being prescribed. Patients also addressed their problems/concerns with use of the drug, which were discussed before discharge.
  
  
  CONCLUSIONS
  Significantly more interventions were identified after patient counseling. Therefore, patient information is essential in medication reconciliation.
authors.affiliation: Department of Hospital Pharmacy, Sint Lucas Andreas Hospital, Amsterdam, Netherlands.
authors.forename: Fatma
authors.initials: F
authors.lastname: Karapinar-Carkit
authors.forename: Sander D
authors.initials: SD
authors.lastname: Borgsteede
authors.forename: Jan
authors.initials: J
authors.lastname: Zoer
authors.forename: Henk J
authors.initials: HJ
authors.lastname: Smit
authors.forename: Antoine C G
authors.initials: AC
authors.lastname: Egberts
authors.forename: Patricia M L A
authors.initials: PM
authors.lastname: van den Bemt
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D037001:Directive Counseling; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000379:methods*; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D009426:Netherlands; D010351:Patient Discharge / Q000592:standards; D010595:Pharmacists / Q000458:organization & administration; D011446:Prospective Studies; D011787:Quality of Health Care