title: Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Medication reconciliation is recognized as an important tool for the prevention of medication discrepancies and subsequent patient harm at care transitions. However, there is inconclusive evidence as to the impact of medication reconciliation at hospital transitions overall, as well as pharmacy-led medication reconciliation services. This review sought to evaluate the impact of pharmacy-led medication reconciliation interventions on medication discrepancies at hospital transitions and to categorize these interventions as single transition interventions or multiple transitions interventions.
  
  
  METHODS
  PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO databases, inclusive from inception to December 2014, were searched. Included studies were published studies in English that compared the effectiveness of pharmacy-led medication reconciliation interventions to usual care and that aimed to assess medication discrepancies at hospital transitions. 'Usual care' was defined as any care where targeted medication reconciliation was not undertaken as an intervention, or if an intervention was conducted, it was not provided by a pharmacist/pharmacy technician.
  
  
  CONCLUSIONS
  Nineteen studies which involved a total of 15 525 adult patients were included. Eleven studies were randomized controlled trials. Overall, pharmacy-led medication reconciliation intervention usually revealed a trend towards reduction in medication discrepancies, compared with usual care. Seventeen studies involving 18 medication reconciliation interventions targeting the various transitions (admission, 9; discharge, 4; and multiple transitions, 5) were included in the meta-analysis. Compared with usual care, single medication reconciliation interventions at transitions in care (either admission or discharge) showed a significant reduction of 66% in patients with medication discrepancies (RR 0·34; 95% CI: 0·23-0·50) in favour of the intervention. There was no difference between groups for interventions targeting multiple transitions (RR 0·88; 95% CI: 0·77-1·02). Subgroup analyses confined to RCTs showed that there were no differences for target of transition (admission vs. discharge), type of intervention (multifaceted intervention vs. medication reconciliation) and setting (single centre vs. multicentre), nor pharmacists vs. pharmacy technicians (non-RCTs only). Importantly, medication discrepancies of higher clinical impact were more easily identified through pharmacy-led interventions than with usual care.
  
  
  CONCLUSIONS
  Pharmacy-led medication reconciliation interventions were found to be an effective strategy to reduce medication discrepancies, and had a greater impact when conducted at either admission or discharge but were less effective during multiple transitions in care. Further studies that are designed to assess the impact of the involvement of pharmacy technicians in medication reconciliation are also needed.
authors.affiliation: Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia.|School of Pharmacy, University of Gondar, Gondar, Ethiopia.
authors.forename: Alemayehu B
authors.initials: AB
authors.lastname: Mekonnen
authors.affiliation: Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia.|Centre for Education and Research on Ageing, Concord Hospital, Sydney, NSW, Australia.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: McLachlan
authors.affiliation: Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia.|Faculty of Medicine, St Vincent's Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia.
authors.forename: Jo-Anne E
authors.initials: JA
authors.lastname: Brien
mesh_terms: D006761:Hospitals; D006801:Humans; D059065:Medication Reconciliation / Q000379:methods*; D015337:Multicenter Studies as Topic; D010343:Patient Admission; D010351:Patient Discharge; D010360:Patient Transfer / Q000379:methods*; D010595:Pharmacists; D010607:Pharmacy Service, Hospital / Q000379:methods*; D016032:Randomized Controlled Trials as Topic
keywords: care transition; hospital; medication discrepancies; medication errors; medication reconciliation; medication review; pharmacy