title: Impact of admission medication reconciliation performed by clinical pharmacists on medication safety.
abstract: BACKGROUND
  Many activities contribute to reduce drug-related problems. Among them, the medication reconciliation (MR) is used to compare the best possible medication history (BPMH) and the current admission medication order (AMO) to identify and solve unintended medication discrepancies (UMD). This study aims to assess the impact of the implementation of admission MR by clinical pharmacists on UMD.
  
  
  METHODS
  This prospective study was carried out in two units of general medicine and infectious and tropical diseases in a 1844-bed French hospital. A retroactive MR performed in an observational period was compared to a proactive MR realized in an interventional period. We used a logistic regression to identify risk factors of UMD.
  
  
  RESULTS
  During both periods, 394 patients were enrolled and 2,725 medications were analyzed in the BPMH. Proactive MR reduced the percentage of patients with at least one UMD compared with retroactive process (respectively 2.1% vs. 45.8%, p<0.001). Patients with at least one UMD during both periods were older compared to patients without UMD (79 vs. 72, p<0.005) and had more medications at admission (7 vs. 6, p<0.0001). UMD occur 38 times more often when there is no clinical pharmacist intervention. Among the 226 UMD detected in both periods, 42% would have required monitoring or intervention to preclude harm, and 10% had potential harm to the patient and 2% were life threatening.
  
  
  CONCLUSIONS
  Proactive MR performed by clinical pharmacists is an acute process of detection and correction of UMD, but it requires a lot of human resources.
authors.affiliation: Department of Pharmacy, Nîmes University Hospital, Nîmes, France; Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, EA2415, University Institute of Clinical Research, Montpellier University, Montpellier, France.
authors.forename: Géraldine
authors.initials: G
authors.lastname: Leguelinel-Blache
authors.affiliation: Department of Pharmacy, Nîmes University Hospital, Nîmes, France.
authors.forename: Fabrice
authors.initials: F
authors.lastname: Arnaud
authors.affiliation: Department of Biostatistics, Epidemiology, Clinical Research and Health Economics, Nîmes University Hospital, Nîmes, France.
authors.forename: Sophie
authors.initials: S
authors.lastname: Bouvet
authors.affiliation: Department of Pharmacy, Nîmes University Hospital, Nîmes, France.
authors.forename: Florent
authors.initials: F
authors.lastname: Dubois
authors.affiliation: Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, EA2415, University Institute of Clinical Research, Montpellier University, Montpellier, France; Department of Biostatistics, Epidemiology, Clinical Research and Health Economics, Nîmes University Hospital, Nîmes, France.
authors.forename: Christel
authors.initials: C
authors.lastname: Castelli
authors.affiliation: Department of Pharmacy, Nîmes University Hospital, Nîmes, France; Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, EA2415, University Institute of Clinical Research, Montpellier University, Montpellier, France.
authors.forename: Clarisse
authors.initials: C
authors.lastname: Roux-Marson
authors.affiliation: Department of General Medicine, Nîmes University Hospital, Nîmes, France.
authors.forename: Valérie
authors.initials: V
authors.lastname: Ray
authors.affiliation: Department of Infectious and Tropical Diseases, Nîmes University Hospital, Nîmes, France.
authors.forename: Albert
authors.initials: A
authors.lastname: Sotto
authors.affiliation: Department of Pharmacy, Nîmes University Hospital, Nîmes, France; Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, EA2415, University Institute of Clinical Research, Montpellier University, Montpellier, France. Electronic address: jean.marie.kinowski@chu-nimes.fr.
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Kinowski
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D059065:Medication Reconciliation / Q000379:methods*; D008875:Middle Aged; D010343:Patient Admission; D061214:Patient Safety; D010595:Pharmacists; D011446:Prospective Studies; D012307:Risk Factors
keywords: Internal medicine; Medication errors; Medication reconciliation; Medication safety; Pharmaceutical care