Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system

Objective: Performing accurate medication history and reconciliation is recognized to reduce medication discrepancies and errors resulting in improved patient safety. This quality improvement project retrospectively evaluated the impact of a newly implemented pharmacy-led admission medication reconciliation program for several hospitals.Methods: In 2020, a pharmacy-led admission medication reconciliation program was implemented in 16 hospitals across a large health system. The program targeted high-risk, complex inpatients admitted through the emergency department and directly to the hospital. Medication history technicians captured the best possible medication list and medication reconciliation pharmacists reviewed the list, collaborating with providers to complete reconciliation, and intervening to optimize drug therapy. A retrospective, pre-post analysis was performed comparing the preimplementation time period of June to November 2019 to the postimplementation time period of June to November 2020. Outcomes evaluated included pharmacy staff productivity, adverse drug events (ADEs), complications, and healthcare professional satisfaction.Results: A total of 311,473 patients were admitted to the 16 hospitals during the pre- and postimplementation time periods. During the six-month postimplementation period, nearly 80,000 medication histories and reconciliations were completed, with 39.9% of those histories requiring medication clarification. Both the ADE rate and complication rate decreased significantly after program implementation, 12% decrease (p < 0.017) and 14% decrease (p < 0.001), respectively. Healthcare professional survey results from nurse, physician, and pharmacist respondents indicated a statistically significant improvement in satisfaction.Conclusion: After implementation of pharmacy-led admission medication reconciliation, patient ADEs and complications decreased during hospitalization, and physician, nurse, and pharmacist satisfaction significantly improved.