cies may have resulted in patient harm during hospitalization and 60 percent may have resulted in patient harm if continued beyond discharge. The most common discrepancy was complete omission of a medication that the patient reported taking prior to hospitalization. The next most frequent discrepancy was a different dose, route or frequency of medication ordered compared to what the patient was taking prior to admission. Gleason says such discrepancies occur most often during patient transfers, when a patient is discharged or moved to another hospital, nursing home or even another floor within the same facility.

The reconciliation process consisted of comparing the patient's medications listed in the admission orders to the medication information documented in: 1) the physician's history and physical; 2) the patient's admission profile, a form completed collaboratively by the nurse and patient (or patient's advocate); and 3) information obtained during the pharmacist-conducted interview. A discrepancy was defined as any inconsistency or difference in the medication regimen noted during this manual comparison process.

The study found that pharmacists are in the best position to perform medication reconciliation.

"We believe that pharmacists are especially suited to obtain medication histories and perform reconciliation based on their education, experience, medication knowledge and patient counseling skills," says Gleason. "Pharmacists can recognize sound-alike and look-alike medications or omissions that others may miss, or dosages that don't seem right."

"The project clearly demonstrated that pharmacists play an integral role in this," adds Gary Noskin, M.D., a study author, the medical director of Healthcare Epidemiology and Quality at Northwestern Memorial and professor at Northwestern's Feinberg School of Medicine. "And what this paper demonstrates is that medication reconciliation is an effective method to prevent medicati
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Contact: Andrew Buchanan
anbuchan@nmh.org
312-926-6503
Northwestern Memorial Hospital
16-Aug-2004

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