title: Medication discrepancies associated with subsequent pharmacist-performed medication reconciliations in an ambulatory clinic.
abstract: OBJECTIVE
  To describe the number of medication discrepancies associated with subsequent medication reconciliations by a clinical pharmacist in an ambulatory family medicine clinic and the proportion of subsequent medication reconciliation visits that were associated with hospital discharge, long-term anticoagulation management, or both.
  
  
  METHODS
  Data on medication reconciliations were collected over a 2-year time period in an ambulatory family medicine clinic for patients taking 10 or more medications.
  
  
  RESULTS
  Medication reconciliation was performed 752 times for 500 patients. A total of 5,046 discrepancies were identified, with more than one-half deemed clinically important. A mean (± SD) of 6.7 ± 4.6 discrepancies per visit (3.5 ± 3.2 clinically important) were identified. The findings showed that the distribution of total discrepancies identified by pharmacist-performed medication reconciliation was significantly different over the course of subsequent medication reconciliations. However, the distribution of clinically important discrepancies was not significantly different; important discrepancies were as likely to be found in later reconciliations as in earlier ones. As subsequent medication reconciliation visits were performed, an increasing proportion consisted of post-hospital discharge visits, long-term anticoagulation managed by a clinical pharmacist, or both.
  
  
  CONCLUSIONS
  Patients with a recent hospital discharge, on long-term anticoagulation management, or both, were more likely to have multiple sessions with a clinical pharmacist for medication reconciliation. These findings can help identify patients for whom medication reconciliation is warranted.
authors.forename: Ann M
authors.initials: AM
authors.lastname: Philbrick
authors.forename: Ila M
authors.initials: IM
authors.lastname: Harris
authors.forename: Jon C
authors.initials: JC
authors.lastname: Schommer
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Fallert
mesh_terms: D000554:Ambulatory Care Facilities; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001071:Appointments and Schedules; D006801:Humans; D059065:Medication Reconciliation; D010351:Patient Discharge; D010595:Pharmacists; D010607:Pharmacy Service, Hospital; D024382:Professional Role; D012017:Referral and Consultation; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants