title: Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.
abstract: BACKGROUND
  Medication history taking is important because clinicians rely on the information that is collected; however, medication histories are often inaccurate and incomplete. The use of a medication at home without a corresponding disease or condition in the patient's records (ie, "unspecified" medication) warrants investigation of the need for that medication. The process of reconciling medications with current diseases or conditions on hospital admission has not been officially advocated by The Joint Commission, but it could help clinicians better assess the continued need for home medications and possibly decrease the use of polypharmacy.
  
  
  OBJECTIVE
  The objectives of this study were to expand on a previous study conducted at our institution by estimating the prevalence of discrepancies between medication histories and reported diseases or conditions in a larger and more diverse patient population, and to determine whether a pharmacist could clarify the reasons for the unspecified medications, thereby enhancing the medication reconciliation process.
  
  
  METHODS
  Patients >or=50 years of age who were taking >or=4 home medications were randomly selected within 24 hours of hospital admission. Medical chart information and home medication lists, obtained shortly after admission, were reviewed retrospectively for the selected patients. Patients were excluded if they were admitted directly to an intensive care unit. Only home medications that the patient continued to take after admission were included in the analysis. Therapeutic hospital formulary substitutes (eg, atorvastatin given instead of pravastatin) were considered to be the same medication. Nonprescription medications, "as needed" medications, and vitamins/supplements taken at home were excluded from analysis. If an unspecified medication was found, a pharmacist proceeded through an algorithm designed to clarify the reason for the unspecified medication. In the event of a common off-label (unapproved) use of a drug, the drug was not considered unspecified.
  
  
  RESULTS
  Home medication lists were available for 300 patients (154 women, 146 men; mean [SD] age, 69 [10.6] years; >98% white) admitted to a 541-bed university hospital between December 2007 and June 2008; a total of 114 patients (38%) had >or=1 unspecified medication. Of the 200 unspecified medications reported in patient charts, the 2 most frequently reported drug classes were proton pump inhibitors and selective serotonin reuptake inhibitors, used by 21% and 11% of patients, respectively. Patients with unspecified medications received a higher mean number of home medications (9.7 vs 7.6 per patient; odds ratio = 1.18; 95% CI, 1.11-1.28; P < 0.001). Rates of discordance were independent of age, sex, and pathway to admission to the emergency department. Ultimately, the study pharmacist was able to clarify 96% of the unspecified medications by applying the study algorithm. Answers were provided by patients (80%), old clinic or hospital chart notes (12%), or physicians (4%); 4% could not be clarified.
  
  
  CONCLUSIONS
  Many of the unspecified medications that were identified in this study have been associated with polypharmacy in the literature. The results of this study suggest that matching home medications with indications for those medications on admission to the hospital enhanced the medication reconciliation process. Direct patient questioning by the pharmacist clarified medication use and contributed to more accurate and complete medication history taking.
authors.affiliation: Department of Pharmaceutical Services, West Virginia University Hospitals, Morgantown, West Virginia, USA.
authors.forename: Lucy A
authors.initials: LA
authors.lastname: Gizzi
authors.forename: Douglas
authors.initials: D
authors.lastname: Slain
authors.forename: Justin T
authors.initials: JT
authors.lastname: Hare
authors.forename: Renee
authors.initials: R
authors.lastname: Sager
authors.forename: Frank
authors.initials: F
authors.lastname: Briggs
authors.forename: Carl H
authors.initials: CH
authors.lastname: Palmer
mesh_terms: D000368:Aged; D000465:Algorithms; D005260:Female; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000379:methods*; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D010343:Patient Admission / Q000592:standards*; D010595:Pharmacists / Q000458:organization & administration; D019338:Polypharmacy; D012189:Retrospective Studies