Value of Pharmacist Medication Interviews on Optimizing the Electronic Medication Reconciliation Process

Purpose:

Few studies have explored the impact of using different methods for obtaining accurate medication histories on medication safety. This study was conducted to compare the accuracy and clinical impact of pharmacist medication histories obtained by electronic medical record review (EMRR) alone with those obtained by direct interviews combined with EMRR.

Method:

This 18-week prospective study included patients who were admitted to the Inpatient Medicine Service at the study institution and who had a pharmacist-conducted medication reconciliation EMRR within 48 hours of hospital admission. A chart review was performed to collect data to determine whether differences existed in the number of discrepancies, recommendations, and medication errors between the EMRR alone group compared to the EMRR combined with the patient interview group.

Results:

Five hundred thirteen discrepancies were identified with the EMRR group compared to 986 from the combined EMRR and patient interview group (P < .001). Significantly more recommendations were made in the combination interview group compared to the EMRR alone group (260 vs 97; P < .001). Fewer medication errors were identified for the EMRR alone group compared to the combination interview group (55 vs 134; P < .001). The most common errors were omitted medications followed by extra dose/failure to discontinue therapy and wrong dose/frequency errors.

Conclusion:

Pharmacist-conducted admission medication interviews combined with EMRR can potentially identify harmful medication discrepancies and prevent medication errors.Key Words: medication reconciliation, pharmacist medication interviewsPatient safety is a national priority for The Joint Commission and the Institute of Medicine.^1–3 It has been estimated that 25% of medication-related injuries are related to preventable medication errors.^4–6 Many of these medication errors are related to unintentional medication discrepancies that occur during transitional points of health care, including hospital admissions, transfers, and discharge.^1,3,6–8 According to The Joint Commission, medication reconciliation is defined as “…the process of identifying the medications currently being taken by an individual.” ³ These medications are compared to newly ordered medications, and discrepancies are identified and resolved. Medication reconciliation is an essential process that health care systems need to implement to avoid unnecessary harm to patients related to medication errors. Approximately 46% of all medication errors and 20% of adverse drug events (ADEs) have been attributed to a lack of medication reconciliation.2,⁷ As a result, The Joint Commission mandated that institutions comply with the National Safety Goal 8 to “accurately and completely reconcile medications across the continuum of care” to prevent drug omissions, duplications, and drug interactions.³ Recently, The Joint Commission revised its Hospital National Patient Safety goals related to medication reconciliation and currently requires hospitals to “maintain and communicate accurate patient medication information.”³ To accomplish this standard, a current list of the patient’s outpatient medications will be obtained upon admission and then compared with the patient’s hospital medication orders in efforts to identify and resolve discrepancies.^1,3 At discharge, The Joint Commission recommends that patients should receive “written information on the medications” that the patients will be taking following discharge from the hospital and should receive patient education on the “importance of managing” their medication information.³Although The Joint Commission recommends that medication reconciliation should be performed at admission, the agency does not provide guidance for how health care institutions should effectively conduct this process. One strategy is to follow the Institute of Medicine’s recommendations to implement information technologies, including the use of electronic medical records and computerized physician order entry systems.^9,10 Ideally, the use of these technologies would facilitate the effectiveness and efficiency of performing chart reviews and, thereby, the medication reconciliation process. Another strategy is to obtain a medication history by directly interviewing the patient and/or the patient’s caregiver.⁹Studies have revealed that obtaining an accurate and complete medication history is an important step for initiating the medication reconciliation process.^6–21 Results from a review of 22 studies demonstrated that 27% to 54% of patients had at least one medication error on hospital admission.⁶ In particular, several studies have described the value of pharmacist-obtained medication histories.^6,13,15,16 These studies have demonstrated that pharmacists identified a higher number of medications or medication discrepancies compared to physicians and other nonphysician providers when obtaining medication histories. Other studies also demonstrate that pharmacist-initiated histories resulted in fewer medication errors^15,18 and ADEs.^11–13Despite these benefits, many health care institutions do not require that pharmacists routinely perform medication interviews as part of the medication reconciliation process, because of workload concerns and lack of pharmacy manpower.^6,15 Moreover, with the use of information technologies, the need to have pharmacists conduct interviews may not be necessary if pharmacists can obtain a complete and accurate medication list through electronic medical chart review. Few studies have explored the impact of using different methods for obtaining accurate medication histories on medication safety.^{9,22, 23} This study was conducted to compare the accuracy and clinical impact of pharmacist medication histories obtained by electronic medical record review (EMRR) alone with those obtained by direct interviews combined with EMRR.