title: Value of pharmacist medication interviews on optimizing the electronic medication reconciliation process.
abstract: OBJECTIVE
  Few studies have explored the impact of using different methods for obtaining accurate medication histories on medication safety. This study was conducted to compare the accuracy and clinical impact of pharmacist medication histories obtained by electronic medical record review (EMRR) alone with those obtained by direct interviews combined with EMRR.
  
  
  METHODS
  This 18-week prospective study included patients who were admitted to the Inpatient Medicine Service at the study institution and who had a pharmacist-conducted medication reconciliation EMRR within 48 hours of hospital admission. A chart review was performed to collect data to determine whether differences existed in the number of discrepancies, recommendations, and medication errors between the EMRR alone group compared to the EMRR combined with the patient interview group.
  
  
  RESULTS
  Five hundred thirteen discrepancies were identified with the EMRR group compared to 986 from the combined EMRR and patient interview group (P < .001). Significantly more recommendations were made in the combination interview group compared to the EMRR alone group (260 vs 97; P < .001). Fewer medication errors were identified for the EMRR alone group compared to the combination interview group (55 vs 134; P < .001). The most common errors were omitted medications followed by extra dose/failure to discontinue therapy and wrong dose/frequency errors.
  
  
  CONCLUSIONS
  Pharmacist-conducted admission medication interviews combined with EMRR can potentially identify harmful medication discrepancies and prevent medication errors.
authors: Professor of Pharmacy Practice and Regional Coordinator, University of the Pacific (UOP), Thomas J. Long (TJL) School of Pharmacy and Health Sciences; Clinical Associate Professor, University of California at San Francisco (UCSF), School of Pharmacy; and Clinical Pharmacist, Internal Medicine , San Francisco VA Medical Center (SFVAMC) .
authors: Audrey
authors: A
authors: Lee
authors: Ambulatory Care Pharmacist, Kaiser Permanente Richmond , California .
authors: Arjun
authors: A
authors: Varma
authors: Pharmacy Information and Pharmacokinetics Program Manager, SFVAMC; Clinical Professor, UCSF, School of Pharmacy; and Adjunct Faculty, UOP, TJL School of Pharmacy and Health Sciences .
authors: Maureen
authors: M
authors: Boro
authors: At the time of the study, Education/Quality Improvement Coordinator and PGY1 Pharmacy Residency Director, SFVAMC; Adjunct Faculty, UOP, TJL School of Pharmacy and Health Sciences; and Clinical Professor, UCSF School of Pharmacy .
authors: Nancy
authors: N
authors: Korman
keywords: medication reconciliation; pharmacist medication interviews