title: Clinical and Financial Impact of Pharmacist Involvement in Discharge Medication Reconciliation at an Academic Medical Center: A Prospective Pilot Study.
abstract: BACKGROUND
  Medication reconciliation is one of the more challenging aspects of inpatient care, and its accuracy is paramount to safe transitions of care. Studies have shown that pharmacists have a role in medication reconciliation through improving patient safety and avoiding costs associated with medication errors. The wide-scale use of pharmacists in this process has been limited by time constraints, cost, and lack of resources.
  
  
  OBJECTIVE
  This study evaluates the impact of pharmacists in resolving medication errors, decreasing readmission rates, and reducing institutional costs during the discharge medication reconciliation process.
  
  
  METHODS
  Pharmacists evaluated discharge medication reconciliation documentation for patients to determine its accuracy, the accuracy of the admission reconciliation documentation, and any potential issues unrelated to accuracy. Analysis of these data determined the time required for pharmacist involvement, the number of errors identified by pharmacists, the quality of pharmacist interventions, the cost avoidance for each error, and the overall impact on hospital readmission.
  
  
  RESULTS
  During the 7-week study period, pharmacists performed 67 discharge medication reviews and identified 84 errors. Seventy-five percent were considered to be significant and 6% were considered to be serious. The 30-day readmission rate in the study cohort was 18% compared with 20% in the control group. Based on the clinical severity scale and pharmacist salaries, pharmacist interventions resulted in $42,300 in cost avoidance.
  
  
  CONCLUSIONS
  Pharmacists involved in this pilot discharge process identified and resolved significant errors on medication reconciliation orders that resulted in a financial benefit to the institution.
authors.affiliation: PGY1 Pharmacotherapy Practice Resident, Department of Pharmacy Services, Medical University of South Carolina (MUSC) , Charleston.
authors.forename: Jamie
authors.initials: J
authors.lastname: Sebaaly
authors.affiliation: PGY 1 Pharmacy Practice Resident, Department of Pharmacy Services, MUSC , Charleston.
authors.forename: Laura Beth
authors.initials: LB
authors.lastname: Parsons
authors.affiliation: Clinical Specialist, Solid Organ Transplantation and Residency Program Director, PGY2 Transplant Residency Program, Department of Pharmacy Services, MUSC , Charleston.
authors.forename: Nicole A Weimert
authors.initials: NA
authors.lastname: Pilch
authors.affiliation: Clinical Specialist, Pulmonary, and Pharmacotherapy Residency Program Director, Department of Pharmacy Services, MUSC , Charleston.
authors.forename: Wendy
authors.initials: W
authors.lastname: Bullington
authors.affiliation: Clinical Specialist, Outcomes Management, Department of Pharmacy Services, MUSC , Charleston.
authors.forename: Genevieve L
authors.initials: GL
authors.lastname: Hayes
authors.affiliation: Director, Department of Pharmacy Services, MUSC , Charleston ; Director, Health System Pharmacy Administration Residency, Clinical Associate Dean for Medical Center Affairs, South Carolina College of Pharmacy , Charleston .
authors.forename: Heather
authors.initials: H
authors.lastname: Easterling
keywords: cost avoidance; discharge; medication errors; medication reconciliation; readmissions