title: Custom and practice: a multi-center study of medicines reconciliation following admission in four acute hospitals in the UK.
abstract: BACKGROUND
  Many studies have highlighted the problems associated with different aspects of medicines reconciliation (MR). These have been followed by numerous recommendations of good practice shown in published studies to decrease error; however, there is little to suggest that practice has significantly changed. The study reported here was conducted to review local medicines reconciliation practice and compare it to data within previously published evidence.
  
  
  OBJECTIVE
  To determine current medicines reconciliation practice in four acute hospitals (A-D) in one region of the United Kingdom and compare it to published best practices.
  
  
  METHODS
  Quantitative data on key indicators were collected prospectively from medical wards in the four hospitals using a proforma compiled from existing literature and previous, validated audits. Data were collected on: i) time between admission and MR being undertaken; ii) time to conduct MR; iii) number and type of sources used to ascertain current medication; and iv) number, type and potential severity of unintended discrepancies. The potential severity of the discrepancies was retrospectively dually rated in 10% of the sample using a professional panel.
  
  
  RESULTS
  Of the 250 charts reviewed (54 Hospital A, 61 Hospital B, 69 Hospital C, 66 Hospital D), 37.6% (92/245) of patients experienced at least one discrepancy on their drug chart, with the majority of these being omissions (237/413, 57.1%). A total of 413 discrepancies were discovered, an overall mean of 1.69 (413/245) discrepancies per patient. The number of sources used to reconcile medicines varied with 36.8% (91/247) only using one source of information and the patient being used as a source in less than half of all medicines reconciliations (45.7%, 113/247). In three out of the four hospitals the discrepancies were most frequently categorized as potentially requiring increased monitoring or intervention.
  
  
  CONCLUSIONS
  This study shows higher rates of unintended discrepancies per patient than those in previous studies, with omission being the most frequently occurring type of discrepancy. None of the four centers adhered to current UK guidance on medicines reconciliation. All four centers demonstrated a strong reliance on General Practitioner (GP)-based sources. A minority of discrepancies had the potential to cause injury to patients and to increase utilization of health care resources. There is a need to review current practice and procedures at transitions in care to improve the accuracy of medication history-taking at admission by doctors and to encourage pharmacy staff to use an increased number of sources to validate the medication history. Although early research indicates that safety can be improved through patient involvement, this study found that patients were not involved in the majority of reconciliation encounters.
authors: School of Pharmacy, University of Bradford, UK; Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK; Pharmacy Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK. Electronic address: r.l.urban@bradford.ac.uk.
authors: Rachel
authors: R
authors: Urban
authors: Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK; School of Health, University of Bradford, UK.
authors: Gerry
authors: G
authors: Armitage
authors: School of Pharmacy, University of Bradford, UK.
authors: Julie
authors: J
authors: Morgan
authors: Manchester Pharmacy School, University of Manchester, UK.
authors: Kay
authors: K
authors: Marshall
authors: School of Pharmacy, University of Bradford, UK.
authors: Alison
authors: A
authors: Blenkinsopp
authors: School of Health, University of Bradford, UK.
authors: Andy
authors: A
authors: Scally
mesh_terms: D006760:Hospitalization; D006769:Hospitals, General / Q000706:statistics & numerical data; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control; D059065:Medication Reconciliation / Q000706:statistics & numerical data*; D010343:Patient Admission; D006113:United Kingdom
keywords: Discrepancies; Hospital; Medication history taking; Medicines reconciliation; Pharmacist