title: Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting.
abstract: OBJECTIVE
  To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting.
  
  
  METHODS
  This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients' community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment.
  
  
  RESULTS
  During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04).
  
  
  CONCLUSIONS
  Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved.
authors.affiliation: Assistant Professor of Pharmacy Practice. Florida Agricultural & Mechanical University . Tallahassee, FL ( United States ). Lillian.smith@famu.edu.
authors.forename: Lillian
authors.initials: L
authors.lastname: Smith
authors.affiliation: Assistant Professor of Pharmacy Practice. Florida Agricultural & Mechanical University . Tallahassee, FL ( United States ). juan.mosley@famu.edu.
authors.forename: Juan
authors.initials: J
authors.lastname: Mosley
authors.affiliation: Director of Pharmacy and Co-Ethics & Compliance Officer. West Florida Hospital Pharmacy. Pensacola, FL ( United States ). sonia.lott@hcahealthcare.com.
authors.forename: Sonia
authors.initials: S
authors.lastname: Lott
authors.affiliation: Clinical Coordinator and Residency Program Director. West Florida Hospital. Pensacola, FL ( United States ). ernie.cyr@hcahealthcare.com.
authors.forename: Ernie
authors.initials: E
authors.lastname: Cyr
authors.affiliation: Department of Mathematics and Statistics Professor. University of West Florida . Pensacola, FL ( United States ). ramin@uwf.edu.
authors.forename: Raid
authors.initials: R
authors.lastname: Amin
authors.affiliation: Florida Agricultural & Mechanical University . Tallahassee, FL ( United States ). emily1.everton@famu.edu.
authors.forename: Emily
authors.initials: E
authors.lastname: Everton
authors.affiliation: Florida Agricultural & Mechanical University . Tallahassee, FL ( United States ). abdullah1.islami@famu.edu.
authors.forename: Abdullah
authors.initials: A
authors.lastname: Islami
authors.affiliation: Florida Agricultural & Mechanical University . Tallahassee, FL ( United States ). linh1.phan@famu.edu.
authors.forename: Linh
authors.initials: L
authors.lastname: Phan
authors.affiliation: Florida Agricultural & Mechanical University . Tallahassee, FL ( United States ). opeyemi1.komolafe@famu.edu.
authors.forename: Opeyemi
authors.initials: O
authors.lastname: Komolafe
keywords: Hospital; Medication Errors; Medication Reconciliation; Patient Admission; Pharmacists; Pharmacy; Pharmacy Service; Students; United States