Background and importance Medicines reconciliation (MR) is identified as a patient safety priority by the World Health Organization (WHO). The pharmacist led medicines reconciliation service at our institution undertakes MR in the WHO priority patient cohort; patients 65 years and over admitted through the emergency department (ED). Completed MR is documented in the general drug chart. On completion of MR, the pharmacist documents in the medical notes that MR has been undertaken. Discrepancies identified through MR are reviewed and actioned, as required, by the medical team.
Aim and objectives To determine if MR completed by pharmacists was being reviewed and actioned by medical teams and to determine any trends in discrepancies not being followed-up.
Material and methods A 1 day hospital wide point prevalence review of MR follow-up by medical teams was undertaken. The review was completed by clinical pharmacists in February 2020. All patients who had an MR completed by a pharmacist in the current general drug chart were reviewed. Data were collected on the number of discrepancies, if the discrepancies were followed-up and the drugs involved.
Results A completed MR in the in-use general drug chart was identified for 88 (21%) inpatients. A total of 226 discrepancies were recorded. 76 patients (86%) had at least one discrepancy requiring medical review. Review and actioning of MR discrepancies was as follows (n=76):
Followed–up in full for 67% of patients
Partly followed–up for 18% of patients
Not followed–up for 15% of patients.
These discrepancies related to 27 individual drugs. Frequently occurring drugs included hydroxocobalamin, folic acid, cholecalciferol, denosumab, inhalers and eye drops. High risk drugs accounted for n=2 of the discrepancies not actioned. In all cases this involved a sedative drug.
Conclusion and relevance In most instances, MR undertaken by pharmacists was being reviewed and actioned by the medical teams. However, there is room for improvement. There is no international published data to benchmark this figure against. The low incidence of incomplete follow-up of high risk drugs is reassuring. A large body of literature demonstrates the benefit of MR to the patient; however, this benefit can only be realised if MR is followed-up. Identification of inhouse initiatives to ascertain barriers to follow-up is recommended.
Conflict of interest No conflict of interest
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