1 2 A feasibility study of interdisciplinary collaboration 3 in the provision of a pharmacist led discharge medication 4 reconciliation service at an Irish hospital 5

8 Abstract Background Medication reconciliation is a 9 basic principle of good medicines management. With the 10 establishment of the National Acute Medicines Programme 11 in Ireland, medication reconciliation has been mandated for 12 all patients at all transitions of care. The clinical pharmacist 13 is widely credited as the healthcare professional that plays 14 the most critical role in the provision of medication rec15 onciliation services. Objectives To determine the feasibility 16 of the clinical pharmacist working with the hospital doctor, 17 in a collaborative fashion, to improve the completeness and 18 accuracy of discharge prescriptions through the provision 19 of a pharmacist led discharge medication reconciliation 20 service. Setting 243-bed acute teaching hospital of Trinity 21 College Dublin, Ireland. Method Cross-sectional observa22 tional study of discharge prescriptions identified using non23 probability consecutive sampling. Discharge medication 24 reconciliation was provided by the clinical pharmacist. 25 Non-reconciliations were communicated verbally to the 26 doctor, and documented in the patient’s medical notes as 27 appropriate. The pharmacist and/or doctor resolved the 28 discrepancies according to predetermined guidelines. Main 29 outcome measures number, type and acceptance of inter30 ventions made by the clinical pharmacist in the resolution 31 of discharge medication non-reconciliations. Number of 32 discharge medication non-reconciliations requiring specific 33 input of the hospital doctor. Results In total, the discharge 34 prescriptions of 224 patients, involving 2,245 medications 35 were included in the study. Prescription non-reconciliation 36 was identified for 62.5 % (n = 140) of prescriptions and 37 15.8 % (n = 355) of medications, while communication 38 non-reconciliation was identified for 92 % (n = 206) of 39 prescriptions and 45.8 % (n = 1,029) medications. Omis40 sion of preadmission medications (76.6 %, n = 272) and 41 new medication non-reconciliations (58.5 %, n = 602) 42 were most common type. Prescription non-reconciliations 43 were fully resolved on 55.7 % (n = 78) of prescriptions 44 prior to discharge; 67.9 % (n = 53) by the doctor, 26.9 % 45 (n = 21) by the clinical pharmacist, and 5.2 % (n = 4) by 46 the joint input of doctor and pharmacist. All communica47 tion non-reconciliations were resolved prior to discharge; 48 97.1 % (n = 200) by the pharmacist, and 2.9 % (n = 6) by 49 both doctor and pharmacist. Conclusion This study dem50 onstrates the how interdisciplinary collaboration, between 51 the clinical pharmacist and NCHD, can improve the com52 pleteness and accuracy of discharge prescriptions through 53 the provision of a pharmacist led discharge medication 54 reconciliation service at an Irish hospital. 5