Abstract

Purpose/Background:

Medication errors are a significant patient safety concern, with over 50% occurring during transitions of care. Accurate medication reconciliation is essential, especially for patients with extensive and complex medication profiles. Incorporating pharmacists in medication histories, verification, and reconciliation has been shown to decrease medication errors at discharge by 42% and decrease emergency department visits.

This study assessed the impact of pharmacist interventions on the discharge medication reconciliation in a medical resident-pharmacist collaboration.

Methodology:

This was a single-site, prospective quality improvement initiative evaluating the number of medication errors prevented through pharmacist-led review and implementation of a collaborative discharge medication reconciliation workflow between pharmacists and medical residents.

Data was collected from medical charts of patients aged 18 years or older who were discharged from internal medicine units assigned to medical residents between January 1 and March 31, 2026. Patients discharged outside of predefined research hours were excluded from the study. The primary outcome was the number of medication errors identified during discharge medication reconciliation. Secondary outcomes included type and severity of medication error avoided, intervention acceptance rate, average time for pharmacist to complete a comprehensive discharge medication review, and average medication error per patient. Excel was utilized for data collection and analysis.

As part of the initiative, medical residents ordered a pharmacy consult for discharge medication reconciliation review during discharge planning phase. This consult prompted the pharmacist to review the discharge medication list and screen for discrepancies between the patient's home medication history, medication administration record (MAR), physician documentation, and planned discharge prescriptions. Medication errors involving omissions, duplications, incorrect dosing, frequency errors, and inappropriate durations of therapy, were communicated to the medical team and addressed prior to discharge. Discharge medication reconciliations were updated accordingly, and prescriptions were transmitted to outpatient pharmacies when appropriate.

Results:

A total of 78 patients were reviewed from the respiratory or general medicine units, of whom 27 had at least one medication error identified. In total, 42 errors were identified and resolved prior to discharge. The error types identified included wrong dose (No=12), wrong frequency (No=8), omission (No=7), duplication of therapy (No=6), wrong drug (No=5), wrong therapy (No=4). The average time for a pharmacist to complete a comprehensive medication review was 13 minutes, this excludes the interval between consult placement and review initiation. The intervention acceptance rate was 100% with an average of 1.6 medication errors identified per patient.

Conclusion:

This evaluation corelates with literature findings and highlights the value of pharmacist-medical resident collaboration in identifying and resolving discharge medication errors. Future directions include expanding the collaborative discharge medication reconciliation workflow to additional inpatient units, ensuring sustainability through engagement of incoming medical residents, and providing targeted education on common discharge medication reconciliation errors.

Publication Date

Spring 5-14-2026

Presented At:

Florida Residency Conference

Content Type

Presentation

Download

Restricted

Available to BHSF community via local IP address or BHSF login.

Share

COinS