title: A Medical Resident-Pharmacist Collaboration Improves the Rate of Medication Reconciliation Verification at Discharge.
abstract: BACKGROUND
  At the Hospital of the University of Pennsylvania (Philadelphia), it is standard practice to perform medication reconciliation at patient discharge. Although pharmacists historically were available to assist resident physicians in the discharge medication reconciliation process, the process was never standardized. An internal review showed a 60%-70% rate of pharmacist review of discharge medication lists, potentially enabling medication errors to go unnoticed during transitions of care. In response, a medical resident- and pharmacist-led collaboration was designed, and a pre-post-intervention study was conducted to assess its effectiveness.
  
  
  METHODS
  A new work flow was established in which house staff notified pharmacists when a preliminary discharge medication list was ready for reconciliation and provided access for pharmacists to correct medication errors in the electronic discharge document with physician approval. Length of stay, average time of day of patient discharge, and readmission data were compared in the pre- and post-intervention periods.
  
  
  RESULTS
  There were 981 discharges in the preintervention period and 1,207 in the postintervention period. The rate of pharmacist reconciliation increased from 64.0% to 82.4% after the intervention (p<.0001). The average number of errors identified and corrected by pharmacists decreased from 0.979 to 0.862 per discharge (p<.0001). There was no significant change in readmission rates or time of discharge after the intervention.
  
  
  CONCLUSIONS
  Redesigning the discharge medication reconciliation process in a teaching hospital to include a review of medical resident discharge medication lists by pharmacists provided more opportunities for discharge medication error identification and correction.
authors.affiliation: Department of Medicine, University of Pennsylvania, Philadelphia, USA.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Caroff
authors.forename: Therese
authors.initials: T
authors.lastname: Bittermann
authors.forename: Charles E
authors.initials: CE
authors.lastname: Leonard
authors.forename: Gene A
authors.initials: GA
authors.lastname: Gibson
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Myers
mesh_terms: D002985:Clinical Protocols; D003299:Cooperative Behavior; D006784:Hospitals, Teaching; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration*; D007902:Length of Stay; D008508:Medication Errors / Q000517:prevention & control; D059065:Medication Reconciliation / Q000458:organization & administration*; D019982:Organizational Case Studies; D010351:Patient Discharge; D010359:Patient Readmission; D010595:Pharmacists / Q000458:organization & administration*; D024382:Professional Role; D057188:Workflow