Background It is widely accepted that the transition of patients across organisations or between professionals is a vulnerable time with regards to medication safety. Approximately 20% of all adverse drug events (ADE) are attributed to poor communication at transitions of care. Completing a medication reconciliation or MedRec for patients at these junctures may be an important means for improving medication safety, and studies have identified that clinical pharmacists contribute positively to MedRec on admission to hospital.

Purpose The study aimed to assess the impact of clinical pharmacy-led MedRec, within the adult patient population upon admission to an acute hospital.

Material and methods This observational, prospective study took place over a 4 week period in March 2018 in an urban, acute, university-affiliated teaching hospital. Data were collected on 205 patients as a part of the normal delivery of services. When MedRec was completed for a patient, the number of apparently unintentional discrepancies were recorded. At 24 and 48 hours, the number of unintentional discrepancies (UD), intentional discrepancies, unresolved discrepancies and the details of the discrepancies were recorded. An expert review panel rated the discrepancies using the numerical rating score according to the potential for harm to the patient if the CP had not intervened.

Results Almost two-thirds of patients (n=205) experienced a CP intervention or endorsement regarding apparently UD. Unintentional discrepancies affected 51% of patients and were associated with 17% of medications reviewed (n=1584). There was a statistically significant positive association between the number of pre-admission medications a patient was taking and UD (r=0.26, p<0.0001). Almost 90% of UD were reported as having the potential to cause moderate harm to the patient: 2.5% were considered to potentially cause serious harm.

Conclusion Pharmacy-led MedRec has a positive effect on patient safety at transitions of care. Longitudinal research is needed to examine the clinical effect that discrepancies have on patient outcomes.

References and/or acknowledgements n/a.

No conflict of interest.