A retrospective review of student pharmacist medication reconciliation activities in an outpatient family medicine center

BACKGROUND Medication reconciliation in the outpatient setting is an important part of preventing medication errors, and is mandated by the Joint Commission. OBJECTIVE To describe and quantify medication reconciliation efforts by student pharmacists in an outpatient family medicine center. METHODS A retrospective review was conducted of medication reconciliation documentation forms completed by student pharmacists during an outpatient clinical rotation between May 2012 and April 2013. Discrepancies were defined as any lack of agreement between the medication list in the electronic medical record and the patient reported regimen. Descriptive statistics were used to report results. RESULTS A total of 557 medication reconciliation documentation forms from 12 student pharmacists were reviewed. The average number of medications per patient interviewed was 9 (range 0-25). A total of 1,783 medication discrepancies were found with an average of 3.2 discrepancies per patient. An additional 272 medication allergy discrepancies were identified. The most common discrepancy was medications the patient was no longer taking (37.3%, n=766). The second most common discrepancy was over-the-counter and herbal medications that had not been added to the medication list (16.2%, n=335). Patient counseling was documented 159 times during the medication reconciliation process. CONCLUSIONS Medication reconciliation by student pharmacists in an outpatient family medicine center resulted in the identification of many discrepancies in medication lists in an electronic health record. Student pharmacists also documented and clarified medication allergies and performed patient counseling.