Clinical pharmacists can help reduce discrepancies in patient medication histories

Clinical pharmacists were instrumental in reducing errors in patients’ physician-acquired medication histories, according to a study published online on March 13 in the Annals of Pharmacotherapy.

The retrospective, single-center cohort study examined patients who were admitted to the acute geriatric department of a Belgian university hospital and followed up by clinical pharmacists between September, 2009, and April, 2010. Patients were limited to those 65 years or older who were taking 1 or more prescription drugs.

The researchers identified 681 discrepancies in 199 patients and nearly 82% of patients had at least 1 discrepancy in the physician-acquired medication history. The clinical pharmacists performed 386 interventions, which were accepted in approximately 72% of the cases. Nearly a quarter of the medication history discrepancies resulted in discrepancies during hospitalization, mostly because the intervention was not accepted, according to the researchers.

Importantly, 278 medication history discrepancies resulted in discrepancies in the discharge letter, accounting for 50.2% of all 554 discrepancies identified in the discharge letters.

“Clinical pharmacist-conducted medication reconciliation can reduce these discrepancies, provided the erroneous information in the physician-acquired medication history is corrected and each intentional change in the medication plan is well-documented during hospitalization and at discharge,” the researchers stated.

The authors concluded that discrepancies in the physician-acquired medication history at admission do not always correlate with discrepancies during hospitalization because of clinical pharmacists’ interventions; however, discrepancies at admission may be associated with at least half of the discrepancies at discharge.