Multidisciplinary approach to inpatient medication reconciliation in an academic setting.

PURPOSE The effectiveness of a multidisciplinary medication reconciliation process was studied in an inpatient family medicine unit of an academic hospital center. METHODS In phase 1 of this two-phase study, nurses, pharmacists, and physicians used an admission medication reconciliation form to reconcile patients' home medications on admission. The form was then reviewed by the pharmacist on the unit and by the attending physician, who reconciled the discharge medication list. The discharge medication list was compared against the patient's home medications list, inpatient medication profile, and prescriptions documented in the electronic medical record to investigate any medication discrepancies. Pharmacists participating in the study documented and categorized medication discrepancies by the potential severity of the error. In phase 2, family medicine medical residents and staff were instructed to include reconciled admission and discharge medication lists in the hospital summary. RESULTS A total of 102 patients formed the study sample. There was no significant difference between phase 1 and phase 2 patients in mean age, sex, and length of hospital stay. Totals of 432 and 367 admission medications required reconciliation during phase 1 and phase 2, respectively. The mean number of admission medication discrepancies decreased from 0.5 per patient in phase 1 to 0 per patient in phase 2. The mean number of discharge medication discrepancies decreased from 3.3 per patient in phase 1 to 1.8 per patient in phase 2. CONCLUSION The mean number of medication discrepancies occurring during admission and discharge decreased after a multidisciplinary medication reconciliation process was implemented in an inpatient family medicine unit of an academic hospital center.