title: Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model.
abstract: OBJECTIVE
  The development, implementation, and pilot testing of a discharge medication reconciliation service managed by pharmacists with offsite telepharmacy support are described.
  
  
  CONCLUSIONS
  Hospitals' efforts to prepare legible, complete, and accurate medication lists to patients prior to discharge continue to be complicated by staffing and time constraints and suboptimal information technology. To address these challenges, the pharmacy department at a 324-bed community hospital initiated a quality-improvement project to optimize patients' discharge medication lists while addressing problems that often resulted in confusing, incomplete, or inaccurate lists. A subcommittee of the hospital's pharmacy and therapeutics committee led the development of a revised medication reconciliation process designed to streamline and improve the accuracy and utility of discharge medication documents, with subsequent implementation of a new service model encompassing both onsite and remote pharmacists. The new process and service were evaluated on selected patient care units in a 19-month pilot project requiring collaboration by physicians, nurses, case managers, pharmacists, and an outpatient prescription drug database vendor. During the pilot testing period, 6402 comprehensive reconciled discharge medication lists were prepared; 634 documented discrepancies or medication errors were detected. The majority of identified problems were in three categories: unreconciled medication orders (31%), order clarification (25%), and duplicate orders (12%). The most problematic medications were the opioids, cardiovascular agents, and anticoagulants.
  
  
  CONCLUSIONS
  A pharmacist-managed medication reconciliation service including onsite pharmacists and telepharmacy support was successful in improving the final discharge lists and documentation received by patients.
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine. ckeeys@clinpharm.com.
authors.forename: Christopher
authors.initials: C
authors.lastname: Keeys
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine.
authors.forename: Bamidele
authors.initials: B
authors.lastname: Kalejaiye
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine.
authors.forename: Michelle
authors.initials: M
authors.lastname: Skinner
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine.
authors.forename: Mandana
authors.initials: M
authors.lastname: Eimen
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine.
authors.forename: Joann
authors.initials: J
authors.lastname: Neufer
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine.
authors.forename: Gisele
authors.initials: G
authors.lastname: Sidbury
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine.
authors.forename: Norman
authors.initials: N
authors.lastname: Buster
authors.affiliation: Christopher Keeys, Pharm. D., BCPS, is Residency Program Director, Sibley Memorial Hospital-Johns Hopkins Medicine, Washington, DC, and Chief Executive Officer, MedNovations, Inc., Laurel, MD. Bamidele Kalejaiye, Pharm. D., is Clinical Pharmacist; and Michelle Skinner, Pharm. D., is Clinical Pharmacist and Training Coordinator, MedNovations, Inc. Mandana Eimen, Pharm.D., is Clinical Pharmacist; JoAnn Neufer, B.S.Pharm., is Director, Pharmacy Services; Gisele Sidbury, Pharm.D., is Clinical Pharmacist; Norman Buster, Pharm.D., is Clinical Pharmacist; and Joan Vincent, M.S.N., is Senior Vice President and Chief Nursing Officer, Patient Care Services, Sibley Memorial Hospital-Johns Hopkins Medicine.
authors.forename: Joan
authors.initials: J
authors.lastname: Vincent
mesh_terms: D004219:District of Columbia; D006284:Health Plan Implementation; D006764:Hospitals, Community / Q000458:organization & administration; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control*; D059065:Medication Reconciliation / Q000379:methods / Q000458:organization & administration* / Q000592:standards; D019982:Organizational Case Studies; D010348:Patient Care Team / Q000458:organization & administration / Q000592:standards; D010351:Patient Discharge; D010607:Pharmacy Service, Hospital / Q000379:methods / Q000458:organization & administration* / Q000592:standards; D010865:Pilot Projects; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration* / Q000592:standards; D017216:Telemedicine / Q000379:methods / Q000458:organization & administration* / Q000592:standards