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Background: Despite medication being the most common healthcare intervention and medication-related incidents being common in hospitals, many rural and remote hospitals in Australia lack onsite pharmacy services due to resource constraints. A Virtual Clinical Pharmacy Service (VCPS) staffed by two senior, rural generalist hospital pharmacists assigned to four hospitals each was implemented in rural and remote facilities to determine whether the VCPS increased adherence to National Safety and Quality Health Service Standards (NSQHS)., Methods: A stepped-wedge randomised controlled trial was employed to sequentially implement a telehealth pharmacy service at one-month intervals in eight hospitals. The primary outcomes were patient-level medication reconciliation completion rates on admission and discharge. Secondary measures evaluated compliance with other NSQHS standards (including Best Possible Medication History, Medication Reconciliation and venous thromboembolism risk assessment), patient outcomes (including representation within 48 h, readmission within 28 days and length of stay), and detection of potential medication-related harms (including pharmacist identified medication related problems, reported medication errors and falls). Patients were invited to complete a patient-reported experience questionnaire. Data were collected from electronic medical records and analysed using mixed logistic regression models to estimate the effectiveness of the VCPS. Antimicrobial usage, falls, and medication errors were analysed at the facility level, while other data were analysed at the patient level., Results: Compared to control (n = 535), patients in the intervention period (n = 527) were more likely to have an admission medication reconciliation completed (Odds Ratio (OR) 11.16, 95% confidence interval (CI) 5.59-22.30, p < 0.001) in models adjusted for the study period. A similar improvement was observed for discharge medication reconciliation completion (OR 4.07, CI 2.38-6.95, p < 0.001), whereas a 33-fold improvement was seen in Best Possible Medication History completion (OR 33.27, CI 17.53-63.14, p < 0.001). The VCPS documented 879 medication related problems, with 61% of patients having at least one medication-related problem documented by a pharmacist. There was no change in length of stay, falls, readmission rates or reported medication error rates; however, the study was not powered to detect these changes. Patient feedback was positive and comparable to in-person care, with 95% (179/189) reporting their overall experience as 'good' or 'very good.' No unintended harms were reported., Conclusions: The VCPS improved compliance with national standards for medication safety, had high patient acceptability and resulted in the detection of clinically relevant medication-related issues in rural and remote settings. The applicability of virtual pharmacy should be explored in further rural and remote locations in addition to other settings such as metropolitan locations with no onsite clinical pharmacists., Ethics Number: GWHREC 2019/ETH13355., Trial Registration: ANZCTR registration number ACTRN12619001757101. Registered on 11/12/2019. Published trial protocol: A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities., Competing Interests: Declarations Ethics approval and consent to participate Ethics approval for this study was granted by Greater Western Human Research Ethics Committee (GWHREC − 2019/ETH13355). The requirement for informed consent was waived by the Greater Western Human Research Ethics Committee because the data utilised in the study was already collected by Western NSW Local Health District. The study was carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable. Competing interests SN, BC, CF, CC, AM, GH are employed by the Local Health District where the research was performed. All other authors declare that they have no competing interests., (© 2024. Crown.)

Background: This study aimed to systematically evaluate interventions and effects that promote involvement in medication safety among older people with chronic diseases and to provide new ideas and references for developing standardized and effective intervention strategies to improve patient involvement in medication safety., Methods: A comprehensive literature search across twelve databases was conducted using both computerized and manual methods. The search was limited to studies designated as randomized controlled trials or quasi-experimental studies and was conducted from the time of each database's inception until September 2023. Two researchers independently carried out qualitative analyses, which included screening the literature, extracting the data, and assessing the quality of the selected studies., Results: This study included five studies involving a total of 388 participants, with interventions aimed at enhancing patient involvement in medication safety, including interactive health education, motivational interviewing, and medication reconciliation. However, direct evidence confirming the positive impact of these interventions in promoting medication safety behaviors among older people with chronic diseases is still lacking., Conclusions: Patient involvement in medication safety behaviors is essential for promoting healthy aging. Medication education, motivational interviewing, and medication reconciliation may improve the willingness and ability of older people to participate. However, limitations in the methodological quality of current studies prevent drawing definitive conclusions, highlighting the urgent need for more high-quality research., Trial Registration: PROSPERO number CRD42023494924., (© 2024. The Author(s).)

Background: Medication reconciliation is essential for optimizing medication use. In part to promote effective medication reconciliation, the Department of Veterans Affairs (VA) invested substantial resources in health information exchange (HIE) technologies. The objectives of this qualitative study were to characterize VA clinicians' use of HIE tools for medication reconciliation in their clinical practice and to identify facilitators and barriers., Methods: We recruited inpatient and outpatient prescribers (physicians, nurse practitioners, physician assistants) and pharmacists at four geographically distinct VA medical centers for observations and interviews. Participants were observed as they interacted with HIE or medication reconciliation tools during routine work. Participants were interviewed about clinical decision-making pertaining to medication reconciliation and use of HIE tools, and about barriers and facilitators to use of the tools. Qualitative data were analyzed via inductive and deductive approaches using a priori codes., Results: A total of 63 clinicians participated. Over half (58%) were female, and the mean duration of VA clinical experience was 7 (range 0-32) years. Underlying motivators for clinicians seeking data external to their VA medical center were having new patients, current patients receiving care from an external institution, and clinicians' concerns about possible medication discrepancies among institutions. Facilitators for using HIE software were clinicians' familiarity with the HIE software, clinicians' belief that medication information would be available within HIE, and their confidence in the ability to find HIE medication-related data of interest quickly. Six overarching barriers to HIE software use for medication coordination included visual clutter and information overload within the HIE display; challenges with HIE interface navigation; lack of integration between HIE and other electronic health record interfaces, necessitating multiple logins and application switching; concerns with the dependability of HIE medication information; unfamiliarity with HIE tools; and a lack of HIE data from non-VA facilities., Conclusions: This study is believed to be the first to qualitatively characterize clinicians' HIE use with respect to medication reconciliation. Results inform recommendations to optimize HIE use for medication management activities. We expect that healthcare organizations and software vendors will be able to apply the findings to develop more effective and usable HIE information displays., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background : Of all adverse drug reactions, 35-45% are due to medication errors and would therefore be preventable. Thus, it is essential to implement effective strategies to prevent medication errors. However, it remains unclear whether medication reviews provide an additional benefit compared to medication reconciliation regarding medication safety. Aim : The present study aimed to evaluate whether medication reconciliation and medication reviews affect the incidence of preventable adverse drug reactions in elderly patients. Method : Non-elective patients 65 years and above admitted to the hospital, taking at least one high-risk drug, were eligible for participation in a three-armed randomized controlled trial. One group went through the medication reconciliation process, a second group received a comprehensive medication review, including medication reconciliation, and the third group did not receive any pharmaceutical intervention (control group). The incidence of preventable adverse drug reactions during hospitalization was set as the primary endpoint. The severity of the preventable adverse drug reactions and the number and clinical relevance of drug-related problems and discrepancies were defined as secondary endpoints. Results : In 207 patients, 74 preventable adverse drug reactions were detected. Neither medication reconciliation nor medication reviews showed a significant impact on the incidence of preventable adverse drug reactions compared to the control group. However, medication reviews significantly reduced the severity of preventable adverse drug reactions (p=0.017). Conclusion : The current study results suggest that medication reviews may have an impact on a clinically relevant outcome by reducing the severity of preventable adverse drug reactions. A significant impact of medication reconciliation on clinically relevant outcomes could not be demonstrated. Based on the results of this study, when deciding on a pharmaceutical intervention comprehensive medication reviews should be preferred over sole medication reconciliation whenever possible.

Medication errors such as medication discrepancies are known as one of the leading cause of death. Medication discrepancies mostly occur during admission and at time transfer of care and discharge. Medication reconciliation process has pivotal role to avert medication discrepancies and improve patient safety and quality. Patients with acute coronary syndrome (ACS) are prone to medication discrepancies due to acute manifestations, simultaneous use of different medicines and having different co-morbidities. This study aimed to determine medication discrepancies identified by medication reconciliation among patients with ACS. In an observational study, patients with ACS admitted to a specialized Hospital in Baneh County, Kurdistan province during September 2023 and January 2024 were included. Medication reconciliation process was done when the patient was admitted. The history of medicine use was collected through interviews with the patient, their caregivers, as well as observing the medicines that were accompany with the patients. Number and type of unintentional medication discrepancies and related factors were evaluated. A total of 280 ACS patients (mean age: 63.8 ± 14.2, male gender: 59.3%) were included in the study. About 68% had at least 2 underlying diseases. The mean daily medicines taken by the patients during admission were 8.5 ± 1.54. The number (percentage) of unintentional inconsistency was observed in 78 (27.3%), and omission (39.7%) and changes in dosage (20.5%) had the highest frequency of unintentional medication discrepancies, respectively. Cardiovascular agents such as anti-dyslipidemia and antiplatelet had the highest frequency of unintentional medication discrepancies. The number of underlying diseases and daily medications before hospitalization increase the odds of discrepancies by 2.15 and 1.49 times, respectively (p-value < 0.05). Medication discrepancies identified by medication reconciliation among patients is relatively common. Unintentional medication discrepancies that have the potential to harm the ACS patients should be given more attention, especially in patients with multiple comorbidities and polypharmacy., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Pharmacoepidemiology has emerged as a crucial field in evaluating the use and effects of medications in large populations to ensure their safe and effective use. This study aimed to assess the agreement of cardiac medication use between a provincial medication database, the Pharmaceutical Information Network (PIN), and reconciled medication data from confirmation through patient interviews for patients referred to cardiac rehabilitation., Methods: The study included data from patients referred to the TotalCardiology Rehabilitation CR program, and medication data was available in both TotalCardiology Rehabilitation charts and PIN. The accuracy of medication data obtained from patient interviews was compared to that obtained from PIN with proportions and kappa statistics to evaluate the reliability of PIN data in assessing medication use., Results: Patient-reported usage was higher for statins (41.6 %) vs. 38.4 %), ACE/ARB, beta-blockers (75.7 %) vs. 73.7 %), DOAC (3.5 %) vs. 2.6 %), and ADP-receptor antagonists (71.0 %) vs. 68.1 %) than if PIN was used. Patient-reported usage data was lower for Ezetimibe (4.7 vs. 4.8 %), Aldosterone antagonists (5.4 %) vs. 5.5 %), digoxin (0.9 %) vs. 1.0 %), calcium channel blockers (19.2 vs. 19.9 %) and warfarin (7.2 %) vs. 8.1 %). The results indicated that the differences between the two sources were very small, with an average agreement of 95.3 % and a kappa of 0.70., Conclusion: The study's results, which show a high level of agreement between PIN and patient self-reporting, affirm the reliability of PIN data as a source for obtaining an accurate assessment of medication use. This finding is crucial in the context of pharmacoepidemiology research, where the accuracy of data is paramount. Further research to explore the complementary use of both data sources will be valuable., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Objective: The aim of this study was to determine the effect of a 7-day extended-hours clinical pharmacy service in the ED on medication prescribing errors upon hospital admission and time to medication reconciliation., Methods: In this retrospective observational study, high-needs patients reviewed by ED pharmacists were compared against those not reviewed, to determine if the service was associated with reduction in admission medication errors. The primary outcome was the rate of medication errors. Errors were independently rated by two senior clinicians using a risk-probability matrix. Secondary outcomes included service's impact on time to best possible medication history (BPMH) and medication reconciliation., Results: There were 242 patients who met the inclusion criteria: 105 intervention vs 137 control. In the intervention arm, 74 patients had at least 1 medication error compared with 113 in the control arm (total errors 206 vs 407). The error rate per 10 medications (interquartile range) was 1.4 (0, 2.9) in the intervention arm compared with 2.7 (1.2, 4.3) in the control arm (risk ratio 0.66 [95% confidence interval: 0.56-0.78]; P < 0.001). There were 33 moderate-risk and no high-risk errors (intervention), compared with 84 moderate-risk and 3 high-risk errors (control). Percent agreement was 98.98% (weighted kappa: 0.62). Time to BPMH and medication reconciliation were reduced from 40.5 and 45.0 h to 7.8 and 40.0 h, respectively., Conclusions: The 7-day extended-hours ED clinical pharmacy service was associated with a reduction in medication prescribing errors in high-needs patients and improved time to BPMH and medication reconciliation., (© 2024 Australasian College for Emergency Medicine.)

Background: General practitioners (GP) and community pharmacists need information about hospital discharge patients' medicines to continue their management in the community. This necessitates effective communication, collaboration, and reliable information-sharing. However, such handover is inconsistent, and whilst digital systems are in place to transfer information at transitions of care, these systems are passive and clinicians are not prompted about patients' transitions. There are also gaps in communication between community pharmacists and GPs. These issues impact patient safety, leading to hospital readmissions and increased healthcare costs., Methods: A three-phased, multi-method study design is planned to trial a multifaceted intervention to reduce 30-day hospital readmissions. Phase 1 is the co-design of the intervention with stakeholders and end-users; phase 2 is the development of the intervention; phase 3 is a stepped wedge cluster randomised controlled trial with 20 clusters (community pharmacies). Expected intervention components will be a hospital pharmacist navigator, primary care medication management review services, and a digital solution for information sharing. Phase 3 will recruit 10 patients per pharmacy cluster/month to achieve a sample size of 2200 patients powered to detect a 5% absolute reduction in unplanned readmissions from 10% in the control group to 5% in the intervention at 30 days. The randomisation and intervention will occur at the level of the patient's nominated community pharmacy. Primary analysis will be a comparison of 30-day medication-related hospital readmissions between intervention and control clusters using a mixed effects Poisson regression model with a random effect for cluster (pharmacy) and a fixed effect for each step to account for secular trends., Trial Registration: This trial is registered with the Australian New Zealand Clinical Trials Registry: ACTRN12624000480583p , registered 19 April 2024., (© 2024. Crown.)

Background: Previous evidence underscores the need to assess potential clinical outcomes resulting from pharmaceutical care interventions and to monitor patient's progress to evaluate their clinical evolution, which is crucial for bolstering the relevance of implementing pharmaceutical care in healthcare services., Aims: To conduct an in-depth analysis of pharmaceutical care practices in a geriatric ward and monitor the clinical outcomes of older people served., Methods: This interventionist study was conducted in the geriatrics ward of a Brazilian university hospital. The research intervention occurred between January and May 2022, with a follow-up conducted for up to 90 days after patients' hospital discharge. Older patients in the geriatrics ward received pharmaceutical care, including medication reconciliation, medication review, and pharmacotherapeutic follow-up, aimed at identifying and resolving drug-related problems (DRPs). The clinical relevance of DRPs and pharmaceutical recommendations was evaluated. Additionally, analyses were conducted on mortality and rehospitalization outcomes in older patients at 30, 60, and 90 days following initial hospital discharge., Results: Of the patients evaluated, a significant 88.3% exhibited at least one DRP (with an average of 2.6 ± 1.9 DRPs per patient), with the majority classified as need/indication problems (38.9%). The acceptance rate of pharmaceutical recommendations was 80.9%, with the majority categorized as very significant relevance (60.4%). DRPs were predominantly of serious clinical relevance (50.9%). In patients whose clinical indicators could be monitored, 95.5% showed some clinical response (in vital signs, laboratory tests and/or clinical status evolution) potentially related to resolved DRPs. Association analysis revealed that a higher number of medications in use before hospitalization correlated with a greater identification of DRPs during hospitalization (p = 0.03). At hospital discharge, 23.6% of patients were no longer using polypharmacy. In total, 16 patients (26.7%) died during the study period. Among patients who did not die during hospitalization (n = 54), 20 patients (37%) experienced rehospitalizations within 90 days following discharge., Conclusion: This study facilitated the consolidation of pharmaceutical care implementation in a geriatric ward. We conducted identification, evaluation, and proposed evidence-based solutions, as well as monitored cases for outcome analysis. It is anticipated that this methodology will inspire future research and the implementation of pharmaceutical care-related services., (© 2024 John Wiley & Sons Ltd.)

Objective: The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease., Data Sources: PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist's role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible., Study Selection and Data Extraction: Six unique interventions were described in 10 studies meeting inclusion criteria., Data Synthesis: Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated., Relevance to Patient Care and Clinical Practice: This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease., Conclusions: The pharmacist's role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MMM, JWS, JBR, JLW, RM, and EO have nothing to disclose. EFB is supported by a grant from the National Institute of Allergy and Infectious Diseases (K23AI143882). The funding source had no role in this manuscript and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Consulting relationship with Wolters-Kluwer. SKG is supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases R01DK121730 and U01DK130010, the National Center for Complementary and Integrative Health U54AT008909, and the Jewish Healthcare Foundation. SKG holds an executive position in the Society of Critical Care Medicine. The content of this manuscript is solely the responsibility of the author and does not represent the official views of the Society of Critical Care Medicine. EDS Personal fees for service on the editorial board for the Clinical Journal of the American Society of Nephrology, royalties as an author for UptoDate, and consulting agreement with Novartis Pharmaceutics for DSMB service. SAS discloses the following speaking fees from Baxter Canada, consulting from AstraZeneca, and honorarium from Otsuka and Novo Nordisk. JAN is supported by grants from NIDDK (R01DK128208, R01DK133539, U01DK12998, and U54DK137307).

Purpose: This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2021 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring, and monitoring/medication reconciliation. Articles evaluating at least one step of the MUP were assessed for their usefulness toward practice improvement., Summary: A PubMed search was conducted in January 2022 for articles published in calendar year 2021 using targeted Medical Subject Headings (MeSH) keywords, and searches of the table of contents of selected pharmacy journals were conducted, providing a total of 7,178 articles. A thorough review identified 79 potentially practice-enhancing articles: 15 for prescribing/transcribing, 17 for dispensing, 4 for administration, 21 for monitoring, and 22 for monitoring/medication reconciliation. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of their importance within health-system pharmacy. The other articles are listed for further review and evaluation., Conclusion: It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful publications. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Purpose: Hospital at home (HaH) program development, spurred by hospital congestion during the COVID-19 pandemic, is moving from a novel idea to a standard of inpatient practice. Understanding pharmacy's clinical role in the HaH patient care team is exceedingly important as programs across the country continue to develop, implement, and expand. The purpose of this study is to describe how clinical pharmacy services are currently provided for home hospital patients and to explain the vital role of pharmacists within the HaH care team., Description: A descriptive study was designed to evaluate pharmacy services provided for home hospital patients from January 1, 2023, to February 28, 2023. Prior to the study period, a focused group of pharmacists routinely active in HaH patient care met to define a standard process for documenting pharmacy services using an electronic documentation system (i-Vent) within the EHR. During the study period, a total of 221 patients were admitted to home hospital at either site representing 3,258 inpatient medication orders with 2,997 medication administrations. Pharmacists signed 903 progress notes and documented 561 interventions across all types. The top 3 pharmacy intervention types were drug administration change (37%), medication reconciliation (29%), and antimicrobial stewardship (15%). Each of the top 3 types were further evaluated by subtype., Conclusion: Documented pharmacy services encompassed a variety of intervention types. The overwhelming majority of patients admitted to the program received pharmacy consultative services, demonstrating how pivotal pharmacists are to the operational success of these programs and clinical care of HaH patients. More research is needed to expose pharmacy potential and facilitate growth for pharmacists practicing in HaH programs., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: Medication reconciliation (MedRec) is an essential health care function that is particularly relevant to pharmacists' expertise and a learning opportunity for pharmacy students. Our objective was to assess change across clinical competence, confidence, and communication skills after the completion of a MedRec rotation by second-year pharmacy students., Methods: A retrospective post-then-pre-survey including 29 questions was developed/delivered to students after the completion of required MedRec hours. The primary end point was the change in 3 domains via summed scores from individual questions. Cohen's difference (d) was used to determine group effect size change. The secondary end points included individual question change, perceived patient impact, and subgroup analyses., Results: Of 115 second-year pharmacy students, 81.7% (n = 94) participated in the study. Students self-reported increases on the Likert scale (0-10) of 2.49 ± 1.90 in clinical competency domain, 3.57 ± 2.13 in confidence domain , and 3.12 ± 2.15 in communication skills domain, representing statistically significant and large group effect changes across all 3. A total of 21 of the 22 individual questions had large group effect changes; 1 question (nursing communications) had a moderate group effect change. Student perception of MedRec impact on patient care (Likert scale 0-10) was positive: post-rotation score 7.39 ± 1.57., Conclusion: To the best of our knowledge, this is the first larger-scale study that examines student-evaluated outcomes of a MedRec-based rotation. Students self-reported high levels of post-rotation competency across all domains; students from ethnic minorities and with less work/MedRec experience increased their lower pre-rotation scores to statistically similar post-rotation scores, compared with non-minority and more experienced peers. Further study of the model and outcomes is advised., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Medication review with follow-up is essential for optimising medication utilisation among the older adult population in primary healthcare., Aim: This study aimed to evaluate the feasibility of implementing medication reviews with follow-up for older adults in community pharmacies and examined potential outcomes on medication use., Method: A pilot randomised controlled trial was conducted with 4 cluster-randomised community pharmacies to assess the feasibility of the intervention. Two community pharmacies served as intervention and control groups. Both groups recruited older adults over 60 who were followed over 6 months. The translated Medication use Questionnaire (MedUseQ) was administered at baseline and 6 months for both groups. The outcomes were to assess the feasibility of conducting medication review with follow-up and the probable medication use outcomes from the intervention., Results: The intervention and control groups comprised 14 and 13 older adults. A total of 35 recommendations were made by pharmacists in the intervention group and 8 in the control group. MedUseQ was easily administered, providing some evidence the feasibility of the intervention. However, there were feasibility challenges such as a lack of pharmacists, collaborative practice, difficulties with the tool language, time constraints, and limited funds. Questionnaire results provided a signal of improvement in medication administration, adherence, and polypharmacy among intervention participants. The incidence of drug related problems was significantly higher in the control group (median = 1) after 6 months, U = 15, z = - 2.98, p = 0.01., Conclusion: Medication review with follow-up is potentialy practical in community pharmacies, but there are feasibility issues. While these challenges can be addressed, it is essential to study larger sample sizes to establish more robust evidence regarding outcomes., Clinical Trial Registry: ClinicalTrials.Gov NCT05297461., (© 2024. The Author(s).)

Background: Medication reconciliation (MedRec) in hospitals is an important tool to enhance the continuity of care, but completing MedRec is challenging., Aim: The aim of this study was to investigate whether queueing theory could be used to compare various interventions to optimise the MedRec process to ultimately reduce the number of patients discharged prior to MedRec being completed. Queueing theory, the mathematical study of waiting lines or queues, has not been previously applied in hospital pharmacies but enables comparisons without interfering with the baseline workflow., Method: Possible interventions to enhance the MedRec process (replacing in-person conversations with telephone conversations, reallocating pharmacy technicians (PTs) or adjusting their working schedule) were compared in a computer experiment. The primary outcome was the percentage of patients with an incomplete discharge MedRec. Due to the COVID-19 pandemic, it was possible to add a real-life post hoc intervention (PTs starting their shift later) to the theoretical interventions. Descriptive analysis was performed., Results: The queueing model showed that the number of patients with an incomplete discharge MedRec decreased from 37.2% in the original scenario to approximately 16% when the PTs started their shift 2 h earlier and 1 PT was reassigned to prepare the discharge MedRec. The number increased with the real-life post hoc intervention (PTs starting later), which matches a decrease in the computer experiment when started earlier., Conclusion: Using queueing theory in a computer experiment could identify the most promising theoretical intervention to decrease the percentage of patients discharged prior to MedRec being completed., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: Unintentional medication discrepancies (UMD) are common amongst geriatric patients. If not addressed, these UMD can lead to suboptimal care and increased health care spending. Ambulatory care pharmacists are trained to identify and resolve UMD, and help tailor medication regimens to assure optimized and safe patient-centered care. The purpose of this retrospective study was to highlight the role of a remote, ambulatory care pharmacist in a geriatric primary care setting. Methods: This was a multicenter, single cohort, retrospective chart review of patients enrolled in a geriatric primary care initiative. Patients met with an ambulatory care pharmacist for a 60-minute telemedicine appointment. The primary endpoint was the percent of patients seen by the ambulatory care pharmacist with at least 1 medication discrepancy identified. Results: A total of 275 visits were scheduled with the ambulatory care pharmacist during the 6-month study period. At least 1 unintentional medication discrepancy (UMD) was identified in 151 patients (66%). At least 1 edit was made to the patient's medication list in 224 patients (97%). The ambulatory care pharmacist made recommendations to the provider in 210 patients (91%). The CPA was utilized in 75 patients (33%). Conclusion: This study highlights the utility of a remote, ambulatory care pharmacist in a geriatric primary care setting. Two-thirds of patients were noted to have at least 1 UMD, and more than 90% of patients were identified as having suboptimal regimens. This initiative shows the impact of a remote, ambulatory care pharmacist on patient care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: In many countries, outpatient and inpatient care are separated. During hospitalization, therefore, switching the outpatient medication to medication of the hospital formulary is required., Methods: We newly designed a switching algorithm in six switching steps (S0-S5) and conducted a study at Bundeswehr Hospital Hamburg (300 beds, 80% civilians). We performed (i) a medication reconciliation to obtain information on outpatient medications and (ii) a medication review to solve drug-related-problems, e.g., drug-drug interactions. We applied (iii) the algorithm to switch medications to the hospital formulary., Results: (i) We identified 475 outpatient medications (median per patient: 4; Q25/Q75 2/7) in 100 patients consecutively admitted to hospital (median age: 71; Q25/Q75: 64/80 years). Of 475 medications, the switching algorithm could not be used since product names were missing in 23.9% and strength in 1.7%. In 3.2%, switching was not required since medication was not prescribed during the hospital stay. (ii) Drug-drug interactions were identified in 31 of 79 patients with more than one medication. (iii) Of 475 medications, 18.5% were on the hospital formulary and therefore did not need to be  switched (S0), 0.2% were on a substitution-exclusion list not allowing switching (S1), 42.0% were switched to a generic medication of the hospital formulary (S2), 1.7% to a therapeutically equivalent medication (S3), 0.4% were patient-individually switched (S4), and for 8.2% a standardized/patient-individual switching was not possible (S5)., Conclusions: Despite comprehensive medication reconciliation, patient- and medication-related information for switching medications to the hospital formulary was often missing. Once all the necessary information was available, standardized switching could be easily carried out according to a newly developed switching algorithm., (© 2024. The Author(s).)

Drug-related problems (DRPs) are critical medical issues during transition from hospital to home with high prevalence. The application of a variety of interventional strategies as part of the transitional care has been studied for preventing DRPs. However, it remains challenging for minimizing DRPs in patients, especially in older adults and those with high risk of medication discrepancies after hospital discharge. In this narrative review, we demonstrated that age, specific medications and polypharmacy, as well as some patient-related and system-related factors all contribute to a higher prevalence of transitional DPRs, most of which could be largely prevented by enhancing nurse-led multidisciplinary medication reconciliation. Nurses' contributions during transitional period for preventing DRPs include information collection and evaluation, communication and education, enhancement of medication adherence, as well as coordination among healthcare professionals. We concluded that nurse-led strategies for medication management can be implemented to prevent or solve DRPs during the high-risk transitional period, and subsequently improve patients' satisfaction and health-related outcomes, prevent the unnecessary loss and waste of medical expenditure and resources, and increase the efficiency of the multidisciplinary teamwork during transitional care., (© 2024. The Author(s).)

Purpose: A comprehensive medication history can contribute to safe therapy. Many approaches aiming to improve medication history taking require significant human resources. To design an efficient process that delivers high-quality medication histories, the individual requirements and resources of a given setting need to be considered. We aimed to provide an overview of existing approaches to medication history taking and their performance in different settings to potentially support the selection of an appropriate procedure., Methods: We searched 3 literature databases (PubMed/MEDLINE, CINAHL, PsycINFO) for publications on approaches to medication history taking and analyzed them with regard to their key components as well as the setting, patient population, assessed outcomes, and efficacy., Results: In total, 65 publications were included and analyzed. The majority of the reported approaches relied on involvement of dedicated staff (n = 43), followed by process-oriented interventions (eg, checklists; n = 15) and information technology (IT)-guided interventions (n = 11). A mean (SD) of 6 (2.9) outcomes were described in each study. Medication discrepancies were reported in 89% of all studies, yet about 75 different descriptions of this outcome were used, making it difficult to compare study results. Only 11 studies applied a sample size calculation and statistical tests. Of those, 10 reported a positive effect of their respective intervention on the quality of medication histories., Conclusion: Most approaches focused on pharmacy staff, which are associated with considerable cost and resources. Therefore, IT-based approaches and patient engagement should be investigated as cost-effective alternatives and tested for superiority in the same setting. Reporting guidelines and standardized methodology are needed to improve the comparability of such studies., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Medication reconciliation (MedRec) helps prevent medication errors. This cross-sectional, nationwide study assessed the knowledge, perceptions, practice, and barriers toward MedRec amongst hospital pharmacy practitioners in the United Arab Emirates. A total of 342 conveniently chosen stratified hospital pharmacists responded to the online survey (88.6% response rate). Mann-Whitney U test and Kruskal-Wallis test were applied at alpha = 0.05 and post hoc analysis was performed using Bonferroni test. The overall median knowledge score was 9/12 with IQR (9-11) with higher levels among clinical pharmacists (p < 0.001) and previously trained pharmacists (p < 0.001). Of the respondents, 35.09% (n = 120) practiced MedRec for fewer than five patients per week despite having a strong perception of their role in this process. The overall median perception score was 32.5/35 IQR (28-35) with higher scores among clinical pharmacists (p < 0.001) and those who attended previous training or workshops (p < 0.001). The median barrier score was 24/30 with an IQR (21-25), where lack of training and knowledge were the most common barriers. Results showed that pharmacists who did not attend previous training or workshops on MedRec had higher barrier levels than those who attended (p = 0.012). This study emphasizes the significance of tackling knowledge gaps, aligning perceptions with practice, and suggesting educational interventions., (© 2024. The Author(s).)

Background: Approximately 50% to 70% of patients have at least 1 medication discrepancy in their initial medication history. These discrepancies can lead to errors on admission and discharge orders and have the potential to cause patient harm and incur added costs associated with increased length of stay and readmission rates. Several studies have demonstrated improved medication history accuracy with pharmacy-conducted services, but variations in practice exist due to challenges with workflow and resources., Objective: This study aims to assess the impact of implementing a patient risk-scoring tool for the prioritization of medication history review by pharmacy staff., Methods: This quasi-experimental, single-center study was conducted at a 948-bed academic medical center as a pilot study with the medication history team which consists of pharmacists and certified pharmacy technicians in the emergency department. The endpoints assessed included pharmacy completion rate of patients in the high-risk category, overall pharmacy conducted medication history rate, and the proportion of medication discrepancies identified after reconciliation., Results: The number of medication histories completed by pharmacy (n=849) decreased by 5.7% in the postintervention period (P = 0.002). Between the preintervention and postintervention period, there were fewer low-risk patients being captured by pharmacy (89.7% to 59.9%, respectively). There was also an increase in the number of medium-risk (Δ=25.4%) and high-risk patients (Δ=4.4%) being captured by pharmacy staff (P < 0.017, α = 0.017)., Conclusion: Use of a risk-scoring tool allowed pharmacy staff to prioritize workflow and capture more high-risk patients for medication history., Competing Interests: Disclosure The authors declare no relevant conflicts of interest or financial relationships., (Copyright © 2024 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Importance: There is currently no consensus on clinically effective interventions for polypharmacy among older inpatients., Objective: To evaluate the effect of multidisciplinary team-based medication optimization on survival, unscheduled hospital visits, and rehospitalization in older inpatients with polypharmacy., Design, Setting, and Participants: This open-label randomized clinical trial was conducted at 8 internal medicine inpatient wards within a community hospital in Japan. Participants included medical inpatients 65 years or older who were receiving 5 or more regular medications. Enrollment took place between May 21, 2019, and March 14, 2022. Statistical analysis was performed from September 2023 to May 2024., Intervention: The participants were randomly assigned to receive either an intervention for medication optimization or usual care including medication reconciliation. The intervention consisted of a medication review using the STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria, followed by a medication optimization proposal for participants and their attending physicians developed by a multidisciplinary team. On discharge, the medication optimization summary was sent to patients' primary care physicians and community pharmacists., Main Outcomes and Measures: The primary outcome was a composite of death, unscheduled hospital visits, and rehospitalization within 12 months. Secondary outcomes included the number of prescribed medications, falls, and adverse events., Results: Between May 21, 2019, and March 14, 2022, 442 participants (mean [SD] age, 81.8 [7.1] years; 223 [50.5%] women) were randomly assigned to the intervention (n = 215) and usual care (n = 227). The intervention group had a significantly lower percentage of patients with 1 or more potentially inappropriate medications than the usual care group at discharge (26.2% vs 33.0%; adjusted odds ratio [OR], 0.56 [95% CI, 0.33-0.94]; P = .03), at 6 months (27.7% vs 37.5%; adjusted OR, 0.50 [95% CI, 0.29-0.86]; P = .01), and at 12 months (26.7% vs 37.4%; adjusted OR, 0.45 [95% CI, 0.25-0.80]; P = .007). The primary composite outcome occurred in 106 participants (49.3%) in the intervention group and 117 (51.5%) in the usual care group (stratified hazard ratio, 0.98 [95% CI, 0.75-1.27]). Adverse events were similar between each group (123 [57.2%] in the intervention group and 135 [59.5%] in the usual care group)., Conclusions and Relevance: In this randomized clinical trial of older inpatients with polypharmacy, the multidisciplinary deprescribing intervention did not reduce death, unscheduled hospital visits, or rehospitalization within 12 months. The intervention was effective in reducing the number of medications with no significant adverse effects on clinical outcomes, even among older inpatients with polypharmacy., Trial Registration: UMIN Clinical Trials Registry: UMIN000035265.

Background: Polypharmacy, a broad term to describe the use of numerous and often unnecessary medications, has been connected to frailty, hospital admissions, falls, and even mortality. The Veterans Health Administration (VHA) developed the VIONE (vital, important, optional, not indicated, and every medication has an indication) dashboard to identify patients with polypharmacy and serve as a framework for deprescribing of medications across VHA facilities where it is used in a variety of practice settings by different disciplines., Objective: This study aimed to describe the implementation of a pharmacist-led, system-wide, deprescribing initiative in the primary care setting., Practice Description: Interdisciplinary education was provided through academic detailing. Subsequently, patients were identified for inclusion in the project using the VIONE dashboard focusing on those at highest risk of polypharmacy and moving down to the lowest risk. Interested patients underwent a medication reconciliation. A clinical pharmacist practitioner (CPP) then contacted the patient to discuss potential deprescribing options. Recommendations were relayed to the primary care provider (PCP) for final approval and communicated to the patient by the pharmacy team., Practice Innovation: Primary care CPPs (n = 3) integrated deprescribing into their standard workload. This service was implemented in the primary care setting across an entire health care system consisting of 16 different primary care teams., Evaluation Methods: The initiative's impact was measured by the number of discontinued medications, the acceptance rate of recommendations by the PCP, the potential annualized cost avoidance, and the number of patients referred to CPP medication management clinics., Results: Among 63 patients, a total of 352 medications were deprescribed resulting in a potential annualized cost avoidance of $184,221. The acceptance rate of discontinuation recommendations was 96.7%. Subsequently, 25.4% of patients were referred to pharmacist-led clinics for disease state management., Conclusion: Embedding deprescribing into standard CPP workflow within the primary care setting facilitated a way for polypharmacy reduction and allowed the expansion of pharmacy-led services at VA Butler Healthcare System., Competing Interests: Disclosure The authors declare no relevant conflicts of interest or financial relationships., (Published by Elsevier Inc.)

Aim: Partnered Pharmacist Medication Charting (PPMC) in patients admitted under general medical units has been shown to reduce medication errors. The aim of this study is to evaluate the impact of the PPMC model on medication errors in patients admitted under cancer units in Victorian hospitals., Methods: A prospective cohort study comparing cohorts before and after the introduction of PPMC was conducted. This included a 2-month pre-intervention phase and 3-month intervention phase. PPMC was implemented during the intervention phase as new model of care that enabled credentialed pharmacists to chart all admission medications, including pre-admission or new medications and cancer therapies, in collaboration with the admitting medical officer. The proportion of medication charts with at least one error was the primary outcome measure., Results: Seven health services across Victoria were included in the study . The majority of health services were using paper-based prescribing systems for oncology. Of the 547 patients who received standard medical medication charting, 331 (60.5%) had at least one medication error identified compared to 18 out of 416 patients (4.3%) using the PPMC model (p < 0.001). The median (interquartile range) inpatient length of stay was 5 (2.9-10.6) days in pre-intervention and 4.9 (2.9-11) days in intervention (p  =  0.88). In the intervention arm, 42 patients had cancer therapy charted by a pharmacist with no errors., Conclusions: PPMC was successfully scaled into cancer units as a collaborative medication safety strategy. The model was associated with significantly lower rates of medication errors, including cancer therapies. PPMC should be adopted more widely in cancer units in Australia., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Medication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient's medication use at home., Aim: In preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients, and data collection to reduce medication discrepancies at discharge and improve medication adherence, and (2) to explore the outcomes of the interventions., Method: Participants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed., Results: Of 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores., Conclusion: Based on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs., (© 2024. The Author(s).)

Background: Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients., Methods: Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A's test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established., Results: POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66-75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m 2 , 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively., Conclusion: The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients., (© 2024. The Author(s).)

Background: Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes., Methods: This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in-home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age-Friendly Health Systems. Fieldnotes included behind-the-scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change., Results: Twenty participants completed a video visit. Participants were 74 years old (range 68-80) taking 12 daily medications (range 7-24). Challenges occurred in half of the visits and took the in-home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password., Conclusions: Clinicians may apply these evidence-based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech-savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges., (© 2023 The American Geriatrics Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objectives: Many medication errors occur during care transitions, which are critical points for patient safety. There is strong evidence in favour of medication reconciliation as a strategy to avoid errors in adults, though few studies have been made in the paediatric setting. Likewise, no recommendations have been established for the selection and/or prioritisation of paediatric patients amenable to reconciliation., Methods: A retrospective study was conducted involving patients subjected to reconciliation by a pharmacist on admission to hospital and who experienced at least one reconciliation error between January and November 2018. Univariable and multivariable analyses were performed to identify possible factors associated with reconciliation error, using a logistic regression model to determine the odds ratio (OR) with the corresponding 95% confidence interval (95% CI)., Results: The group of patients with at least one reconciliation error included 334 patients, compared with the group of patients without reconciliation errors, which included 1426 patients. It was determined that schoolchildren and adolescent patients had a risk of presenting a reconciliation error on hospital admission that was more than double for younger patients (OR 2.32, 95% CI 1.26 to 4.25, and OR 2.68, 95% CI 1.44 to 4.99, respectively). This risk was multiplied by five if we compared polymedicated patients versus non-polymedicated patients (OR 4.48, 95% CI 3.35 to 5.99). Patients with a neurological or onco-haematological underlying disease had a 12 and 10 times higher risk of presenting a reconciliation error compared with patients with other types of underlying diseases (OR 11.97, 95% CI 7.57 to 18.92, and OR 9.96, 95% CI 6.09 to 16.28, respectively). Finally, patients with narrow therapeutic index medicines in their usual treatment had an almost three times greater risk of presenting a reconciliation error when admitted to the hospital, although this last factor was not determined as an independent risk factor as for the others (OR 2.98, 95% CI 2.22 to 3.99)., Conclusions: The paediatric population is characterised by a number of risk factors for reconciliation error. Knowledge of these factors can allow the prioritisation of medication reconciliation in a concrete group of patients. In order to generalise the results obtained in this study, they must be confirmed in other paediatric care settings involving larger samples and different types of patients., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Individuals with psychiatric disorders are at increased risk for treatment non-adherence and related complications, especially during transitions of care. Medication reconciliation is now a standard process during hospital admissions that is uniformly recommended by international organizations to aid in safe and effective care transitions. Pharmacy-led medication reconciliation (PMR) practices are poised to represent a standardized method of reconciliation attempt within this underserved population with complex medication histories. Methods: A retrospective cross-sectional study using medical chart review was conducted for all adults admitted to the inpatient psychiatric service at a community hospital in Buffalo, NY, during 2 months in 2018. Outcomes were 30- and 180-day psychiatric readmission rates, 30- and 180-day visit rates to the outpatient comprehensive psychiatric emergency program (CPEP), and composite 30- and 180-day relapse. Receipt of pharmacy-led medication reconciliation was identified from pharmacy documentation in the electronic medical record. Results: 78% of patient's medication lists on admission were reconciled, with 49% of reconciliations made by the inpatient pharmacy. Presence of a PMR did not alter the odds of inpatient readmission alone, however patients without a PMR were found to have 2.13 times higher odds of visiting the hospital's outpatient CPEP within 30-days ( P = .012) and 1.9 times higher odds of any composite psychiatric relapse within 30-days ( P = .024). Conclusions: Implementation of hospital-wide pharmacy-led medication reconciliation on admission may help reduce psychiatric relapse across multiple care settings., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This study aims to investigate the impact of medication reconciliation (MR) conducted by pharmacists before patient enrollment and the initiation of investigational treatments. By implementing MR, the primary objective is to evaluate the extent to which the inclusion of patients with prohibited or not recommended concomitant medications in clinical trials can be significantly reduced., Materials and Methods: The study included all patients who participated in clinical trials and underwent MR between September 1, 2015, and September 1, 2020. To identify prohibited or monitored drugs, protocols and investigator's brochures provided by the sponsor were meticulously reviewed and taken into consideration., Results: MR was performed for 501 patients, uncovering 35% of the medications they were currently taking. Through the pharmaceutical analysis, a total of 346 drug-drug interactions (DDIs) were identified, of which 188 required monitoring and 158 were strictly prohibited. More than half of the prohibited medications were herbal drugs. A significant portion of these prohibited drugs were discontinued, with only 6% being replaced by suitable alternatives. The implementation of MR played a crucial role in the identification of 51% of the prohibited or monitored drugs that were initially overlooked by oncologists., Conclusion: MR is a highly effective measure aimed at reducing the risk of DDIs with investigational drugs, thereby minimizing protocol deviations and enhancing patient care. Sponsors of clinical trials value its implementation and recognize the substantial benefits it brings to the entire trial process. Consequently, many sponsors willingly provide funding to investigational sites that adopt MR as part of their standard practice, acknowledging its critical role in ensuring patient safety and maintaining data integrity throughout the course of clinical research studies.

Background: Pharmacy-led medication history collection and reconciliation have demonstrated decreased medication errors, increased patient safety, and improved cost-savings. However, literature lacks documented efforts to implement such services in the preoperative space, where having accurate medication lists following complex procedures with high postoperative admission rates is critical., Objectives: The purpose of this study was to describe the implementation of a telephonic pharmacy student and pharmacist-led preoperative medication reconciliation program., Practice Description: The service was piloted using third- and fourth-year pharmacy students to conduct telephonic medication histories for urologic surgical oncology patients. Weekly reports identified eligible patients with scheduled procedures within 2 weeks' time. Using standardized methods for patient communication and documentation, students authored telephone encounter notes that were reviewed and signed by pharmacist preceptors. Pharmacist preceptors also reconciled home medication lists based on students' findings., Practice Innovation: A standardized preoperative medication reconciliation process was developed and implemented utilizing third- and fourth-year pharmacy students. Resulting notes were available for surgical staff on the day of patients' procedures and upon potential postoperative admission., Evaluation Methods: A retrospective chart review was conducted to evaluate successfully documented medication histories collected by pharmacy students within the pharmacy-led preoperative medication reconciliation program., Results: Forty-six medication reconciliation notes were identified between August 2021 and February 2022, and 39 met inclusion criteria. Amongst the 177 medication additions, deletions, and edits, deletions were the most common, and 95% of patients had at least 1 medication discrepancy identified. A total of 33 medication classes were represented by the identified discrepancies, and each encounter took an average of 33 minutes to complete., Conclusion: Preoperative medication reconciliation services can be successfully accomplished through a telephonic pharmacy student and pharmacist-led workflow. Accurate medication histories aid in minimizing medication errors and increasing patient safety., Competing Interests: Disclosure The authors declare no relevant conflicts of interest or financial relationships., (Copyright © 2024 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Introduction: Hospitalization and discharge in older patients are critical and clinical pharmacists have shown to ameliorate risks. Our objective was to assess their benefit as part of the geriatric team regarding rehospitalizations and related outcomes after discharge focusing on general practitioners' decision to continue or change discharge medication (GPD)., Methods: Prospective implementation study with 6-month follow-up in an acute geriatric clinic. Patients ≥70 years with comorbidities, impairments, and a current drug therapy were consecutively assigned to three groups: control group (CG), implementation group (IG), and wash-out group (WG). CG only received medication reconciliation (MR) at admission; IG and their hospital physicians received a pharmaceutical counseling and medication management; during WG, pharmaceutical counseling except for MR was discontinued. We used a negative-binomial model to calculate rehospitalizations and days spent at home as well as a recurrent events survival model to investigate recurrent rehospitalizations., Results: One hundred thirty-two patients (mean age 82 years, 76 women [57.6%]) finished the project. In most of the models for rehospitalizations, a positive GPD led to fewer events. We also found an effect of pharmaceutical counseling on rehospitalizations and recurrent rehospitalizations in the CG versus WG but not in the CG versus IG models. 95.3% of medication recommendations by the pharmacist in the clinic setting were accepted. While the number of positive GPDs in CG was low (38%), pharmaceutical counseling directly to the GP in IG led to a higher number of positive GPDs (60%)., Discussion: Although rehospitalizations were not directly reduced by our intervention in the CG versus IG, the pharmacist's acceptance rate in the hospital was very high and a positive GPD led to fewer rehospitalization in most models., (© 2024 S. Karger AG, Basel.)

Background: Most research on the impact of medication reconciliation on patient safety focused on the retroactive model, with limited attention given to the proactive model., Objective: This study was conducted to compare the proactive and retroactive models in patients hospitalized for acute decompensated heart failure., Methods: This prospective, quasi-experimental study was conducted over six months, from June to November 2022, at the cardiology unit of an academic hospital in Iran. Eligible patients were those hospitalized for acute decompensated heart failure using a minimum of five regular medications before admission. Medication reconciliation was performed in 81 cases using the proactive model and in 81 using the retroactive model., Results: 556 medications were reconciled using the retroactive model, and 581 were reconciled using the proactive model. In the retroactive cases, 341 discrepancies (both intentional and unintentional) were identified, compared to 231 in the proactive cases. The proportion of patients with at least one unintentional discrepancy was significantly lower in the proactive cases than in the retroactive cases (23.80% versus 74.03%). Moreover, the number of unintentional discrepancies was significantly lower in the proactive cases compared to the retroactive cases (22 out of 231 discrepancies versus 150 out of 341 discrepancies). In the retroactive cases, medication omission was the most frequent type of unintentional discrepancy (44.00). About, 42.70% of reconciliation errors detected in the retroactive cases were judged to have the potential to cause moderate to severe harm. While the average time spent obtaining medication history was similar in both models (00:27 [h: min] versus 00:30), the average time needed to complete the entire process was significantly shorter in the proactive model compared to the retroactive model (00:41 min versus 00:51)., Conclusion: This study highlighted that the proactive model is a timely and effective method of medication reconciliation, particularly in improving medication safety for high-risk patients.

Aim: The study aimed to assess the impact of pharmacist interventions during the transition of care., Background: Medication discrepancies can occur at various levels of transition, such as during admission, the transition from emergency to special wards or from special to general wards, and during discharge. Discrepancies can be detected through the process of medication reconciliation., Objective: The objective of the study was to compare discrepancies among patients exposed to pharmacist intervention groups and those who were not and assess the perception of healthcare professionals and patients towards integrating pharmacists in the transition care process., Methods: A pharmacist-led interventional study was conducted for six months on patients above 18 years of age and either sex who were admitted to the emergency department, had chronic diseases, and subsequently transferred to another department (any). The patients were randomized into intervention and control groups. The pharmacist performed a medication reconciliation and medication review to identify discrepancies in every transition in both the groups, and then reported to the treating physician to resolve in the intervention group., Results: Among the 73 patients recruited in the study, 152 discrepancies were identified. The total discrepancies observed in the control and intervention groups were 78 (51.3%) and 74 (48.6%), respectively. The majority, 35.53%, were found during the transition from emergency to special wards. The physician, upon pharmacist recommendations, accepted and resolved 48 discrepancies in the intervention group. The healthcare professional acceptance rate of pharmacist interventions was 64.86%., Conclusion: The transitions of care are at risk for errors due to medication discrepancies, and pharmacists could potentially identify and resolve discrepancies. Healthcare professionals and patients reported to be satisfied by the involvement of clinical pharmacists in the healthcare team., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: Medication reconciliation (MC) is one of the main strategies to reduce medication errors in care transitions. In Spain, several guidelines have been published with recommendations for the implementation and development of MC aimed at the adult population, although paediatric patients are not included. In 2018, a study was carried out that led to the subsequent publication of a document with criteria for selecting paediatric patients in whom CM should be prioritised., Objectives: To describe the characteristics of paediatric patients most likely to suffer from errors of reconciliation (EC), to confirm whether the results of a previous study can be extrapolated., Methodology: Prospective, multicentre study of paediatric inpatients. We analysed the CE detected during the performance of the CM on admission. The best possible pharmacotherapeutic history of the patient was obtained using different sources of information and confirmed by an interview with the patient/caregiver., Results: 1043 discrepancies were detected, 544 were identified as CD, affecting 317 patients (43%). Omission of a drug was the most common error (51%). The majority of CD were associated with drugs in groups A (31%), N (23%) and R (11%) of the ATC classification. Polymedication and onco-haematological based disease were the risk factors associated with the presence of CD with statistical significance., Conclusions: The findings of this study allow prioritisation of CM in a specific group of paediatric patients, favouring the efficiency of the process. Onco-haematological patients and polymedication are confirmed as the main risk factors for the appearance of CD in the paediatric population., (Copyright © 2023 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Care transitions are a challenging and crucial point for many high-risk patients; errors in medication use can result in preventable hospital readmissions, which worsen patient outcomes and result in decreased reimbursement and increased expenses for health systems. Transitions of care (TOC) is an opportunity where pharmacists in the outpatient setting can prevent medication errors and decrease hospital readmissions., Objective: The primary objective of this study was to evaluate the impact of pharmacist-conducted comprehensive medication reviews (CMRs) on 30-day hospital readmission rates. Secondary objectives included medication therapy problems (MTPs) identified, recommendations or interventions made, and impact on cost savings., Methods: Patients discharged from an Intermountain Health hospital with a high readmission risk score, value-based insurance plan, and primary care provider (PCP) at one of 21 primary care clinics were identified using an internal report. Patients were contacted by a pharmacist after discharge for a CMR; pharmacists then relayed any MTPs and therapeutic recommendations to the PCP before the patient's follow-up appointment. Data were retrospectively collected and analyzed., Results: A total of 2717 discharges occurred throughout Intermountain Health and affiliate clinics from October 5, 2020, to January 31, 2021; 30-day readmissions rates in the pharmacist intervention group versus the comparator group were 24/191 (12.57%) versus 511/2526, (20.23%), respectively, yielding a statistically significant difference (P < 0.05). The absolute risk of readmission was reduced by 7.66%, with a number needed to treat of 14. Approximately 14 readmissions were prevented in the pharmacist intervention group, resulting in an estimated cost savings of $212,800 and return on investment of $16.19:1., Conclusion: Pharmacist intervention in the outpatient setting in high-risk TOC patients resulted in decreased 30-day readmission rates and increased cost savings. Further investigation is warranted to identify patient factors where pharmacist intervention is most beneficial., (Copyright © 2023 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to investigate whether it was possible to decrease the time used for medication reconciliation (MR) in the emergency department without compromising quality. A more efficient method will enable more patients to receive MR as early as possible after admission to hospital., Methods: Potential key factors for improvement of the standard method of MR by clinical pharmacists were identified through an observational period. A revised method was developed, focusing on decreasing time spent on the patient interview by use of a condensed checklist and probing questions based on information from a prescription database. Non-inferior quality (proportion of patients with at least one identified medication discrepancy and number of identified medication discrepancies per patient) of the revised method was evaluated using a before-after study design with 200 individuals in each group. Non-inferiority limit was set at 10%. The Mann-Whitney U test was used for statistical evaluation of the difference in time use per patient in the MR process between the before and after group., Results: Mean age of the included patients was 78 years in both groups. The time used for MR in the after group was 34% shorter (37 min vs 56 min, p<0.0001) compared with the before group. The revised method was shown to be non-inferior compared with the original method with respect to the proportion of patients with at least one identified discrepancy (81%, 95% CI 76% to 86% vs 79%, 95% CI 73% to 84%). Also, non-inferiority was shown for the number of identified discrepancies per patient, where the average number of discrepancies per patient was 1.9 (95% CI 1.7 to 2.1) in both groups., Conclusion: This study showed that it was possible to speed up the MR process without compromising its effectiveness in identifying medication discrepancies., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objective: Medication safety problems are common post-hospital discharge, and an important global healthcare improvement target. The Transfers of Care Around Medicines (TCAM) service was launched by a National Health Service Trust in the North-West of England, initially focusing on patients with new or existing Monitored Dosage Systems (MDS). The TCAM service is designed to enable the prompt transfer of medication information, with referrals made by hospitals at discharge to a named community pharmacy. This study aimed to explore the utilisation and impact of the TCAM service on medication safety., Methods: The evaluation included a descriptive analysis of 3033 anonymised patient referrals to 71 community pharmacies over a 1-year period alongside an assessment of the impact of the TCAM service on unintentional medication discrepancies and adverse drug events using a retrospective before-and-after study design. Impact data were collected across 18 general practices by 16 trained clinical pharmacists., Results: Most patient referrals (70%, 2126/3033) were marked as 'completed' by community pharmacies, with 15% of completed referrals delayed beyond 30 days. Screening of 411 patient records by clinical pharmacists yielded no statistically significant difference in unintentional medication discrepancies or adverse drug event rates following TCAM implementation using a multivariable regression analysis (unintentional medication discrepancies adjusted odds ratio = 0.79 [95% confidence interval 0.44-1.44, p = 0.46]; and adverse drug events adjusted odds ratio = 1.19 [95% confidence interval 0.57-2.45, p = 0.63]), although there remained considerable uncertainty., Conclusions: The TCAM service facilitated a number of community pharmacy services offered to patients with monitored dosage systems; but the impact of the intervention on unintentional medication discrepancies and adverse drug event rates post-hospital discharge for this patient group was uncertain. The results of this exploratory study can inform the ongoing implementation of the TCAM service at hospital discharge and highlight the need to understand service implementation in different contexts, which may influence its impact on medication safety., (© 2023. The Author(s).)

Purpose: Hospital discharge represents a difficult care transition for patients, with the potential for medication-related problems (MRPs) and adverse events. Medication reconciliation is widely accepted as a best practice to minimize MRPs at the time of discharge. Pharmacists can play a key role in identification and resolution of MRPs, although pharmacist reconciliation usually occurs after provider medication reconciliation. This workflow is often inefficient and results in duplication of work within the care team. A prospective pharmacist-led pilot program with preparation of discharge medication orders for provider review, also known as pended medication orders, was investigated to determine its impact on MRPs and discharge processing time., Summary: Patient discharges from February through April 2022 were compared for 2 hospital medicine services at a large academic medical center. One group participated in the pilot workflow, while the other used standard discharge workflows. The pilot group had a significant decrease in the average number of clinical interventions made by a pharmacist after provider orders were placed (52.4% decrease; P = 0.03) and a nonsignificant reduction in the time from provider order entry to completion of the final pharmacist medication reconciliation (47.6% reduction; P = 0.18) compared to the group using standard workflows., Conclusion: Pharmacist-led, prospective discharge medication reconciliation with pending of medication orders for provider review increases overall discharge efficiency. Data from this project and previous studies support an expanded pharmacist role in the discharge process and continued high-level collaboration between pharmacists and providers., (© American Society of Health-System Pharmacists 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Medication reconciliation is a key point of the v2020 certification. The main objective of this study was to evaluate this activity over one year, including the first epidemic wave at COVID-19. The secondary objectives were to identify the obstacles and levers and to evaluate doctor satisfaction., Methods: This was a retrospective study of drug reconciliations performed on admission during 12 months of the emergence of COVID-19. Patients aged 65 years and older from orthopedic and visceral surgery, acute hospitalization and conventional medicine units were included. Unintentional discrepancies were analyzed. The obstacles and levers were identified by means of a focus group. Doctors' satisfaction was collected using online quiz., Results: A total of 760 patients were conciliated, of which 27% (n=208) by hospital pharmacy technicians. A decrease in activity was observed during the first epidemic wave. An unintentional discrepancy was found in 77% of patients, and only 48% were corrected by the prescriber. These results were impacted by the pandemic. The pharmaceutical team was mobilized in the logistical management of the crisis, but it was able to adapt in order to perpetuate the activity. Doctors are satisfied with the process., Conclusions: Medication reconciliation on admission is essential for the prevention of iatrogeny, particularly with the impact of the COVID-19 pandemic in healthcare institutions., (Copyright © 2023 Académie Nationale de Pharmacie. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: To evaluate the impact of a collaborative drug therapy management (CDTM) agreement allowing a pharmacist to automatically prescribe refills of discharge medications to patients' preferred outpatient pharmacy on utilization of a hospital discharge prescription program and hospital readmission rates., Methods: This was a single-center, quasi-experimental pre-post intervention study. Patients aged 18 years or older discharged from the cardiology services to home were eligible for inclusion in the study. The CDTM agreement was initiated on July 1, 2019. Patients discharged to home from July 1, 2018, to June 30, 2019, were assigned to the historical control group. The primary outcome was the difference in the proportion of 
patients who used the bedside medication delivery service at hospital discharge between the groups. Secondary outcomes included 30-day hospital readmissions and a descriptive analysis of medications prescribed by a pharmacist through the program. A χ2 test was used to assess the primary outcome, and multivariable logistic regression was used to assess hospital readmissions., Results: In total, 1,704 and 2,200 patients were discharged in the control and CDTM groups, respectively. The CDTM group had a greater proportion of patients who participated in the discharge prescription program compared to the historical control group (77.8% vs 68.7%; P < 0.0001). There was no difference in 30-day hospital readmission rate between the groups (adjusted odds ratio, 1.01; 95% confidence interval, 0.83-1.23; 
P = 0.94)., Conclusion: A CDTM protocol to improve the availability of medication refills at a patient's regular outpatient pharmacy improved utilization of a bedside medication delivery service but did not change 30-day readmission rates., (© American Society of Health-System Pharmacists 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Pharmacists and case managers positively impact patient health outcomes during the transition of care from the hospital to the home. However, the combination of both specialties completing post-discharge telephone calls has not been clearly studied., Objectives: The primary outcome of this research was to identify the combined impact of post-discharge telephone calls from both pharmacists and case managers on all cause 30-day hospital readmissions when compared to a call from either group alone. Secondary outcomes included 30-day emergency department visits and types of medication therapy problems identified by pharmacists during the call., Methods: This retrospective study included high risk patients eligible for a post-discharge telephone call from both pharmacy and case management from January 1, 2021 to September 1, 2021. Patients were excluded if they did not complete a telephone call from either group or were deceased within 30 days of discharge. Results were analyzed using descriptive and chi square analyses., Results: Eighty-five hospital discharges were included in the study, with 24 patients receiving post-discharge telephone calls from both case management and pharmacy, and 61 patients receiving a call from either group alone. Thirty-day all cause readmissions occurred in 13% of the combined group versus 26% in either group alone (p = 0.171). Thirty-day all cause emergency department visits were 8% in the combined group versus 11% in either group alone (p = 0.617). Of the 38 post-discharge encounters completed by pharmacists, 120 medication therapy problems were identified, averaging over 3 medication issues per patient., Conclusions: Collaboration amongst pharmacists and case managers has the potential to positively impact patient outcomes upon discharge from the hospital. Health systems should work to integrate transitions of care services performed across disciplines., Competing Interests: Declaration of competing interest Cardinal Health provided grant funding for the pharmacy students employed in the pilot transition of care program at Geisinger. Cardinal Health did not have any involvement in the research and/or preparation of the article., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Patients with cancer need care from a multidisciplinary team due to the complexity of the clinical picture and proposed treatment. Hospital discharge is a critical step, because pharmacotherapy changes may occur during hospitalization, leading to potential medication-related problems at home., Objective: To identify publications which describe the activities performed by the pharmacist at the hospital discharge of patients with cancer., Method: This is an integrative systematic literature review. A search was carried out in the MEDLINE databases, via Pubmed, Embase, and Virtual Health Library, using the following descriptors: "Patient Discharge", "Pharmacists", "Neoplasms." Studies that reported activities performed by the pharmacist at the hospital discharge of patients with cancer were included., Results: Five hundred and two studies were identified, of which seven met the eligibility criteria. Most were conducted in the United States (n = 3), and the rest in Belgium, Brazil, Canada, and Italy. Among the services provided by the pharmacist at discharge, medication reconciliation was the most widely described. Other activities such as counseling, education, identification, and resolution of drug-related problems were also carried out., Conclusion: In the scenario of hospital discharge of patients with cancer, the participation of pharmacists is still to be seen as of significance in regards to publications. Despite this, the results suggest that the actions of this professional contribute to patient orientation and the safe use of prescription drugs for use at home.

Objectives: To evaluate the role of clinical pharmacists in cardiac day wards., Methods: A service evaluation was conducted during 24 February 2020-27 March 2020 to assess the role of clinical pharmacists for all patients admitted to an Australian tertiary hospital cardiac day ward., Key Findings: Overall, 297 patients were included. Medication review occurred for 80% (237/297) and a best possible medication history was obtained for 65% (193/297) of patients. Acceptance of interventions for medication-related problems was 93% (84/90). When compared with medication plans outlined in standard catheterisation laboratory documentation without pharmacist input, a pharmacist medication review resulted in increased documentation of medication plans in the patient's medical record at the time of discharge (20% (1/5) versus 95% (142/150), P < 0.001)., Conclusion: Pharmacists can optimise the medication management of patients in cardiac day wards by performing medication review, and facilitating implementation and communication of medication changes at hospital discharge to patients and primary healthcare providers., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Accurate medication lists are essential data required to make clinically informed decisions. Obtaining a comprehensive, up-to-date medication list is difficult for clinicians. Patients have limited input into reviewing and reconciling their own medication data. Ideally, a medication list would comprise a 360-degree view of all prescribed, dispensed, purchased medications and would seamlessly connect patients and providers to medication data from multiple sources. While an ideal medication list would capture every aspect of medication management, in reality a Best-Possible Medication History (BPMH) is a more achievable goal. In an effort to realize a BPMH and to facilitate the goals of the State of Connecticut's Office of Health Strategy's Medication Reconciliation and Polypharmacy Committee (MRPC), we engaged stakeholders (patients, clinicians, advocates) in focus-groups and interviews to solicit feedback on the user interface requirements for a BPMH. Feedback was obtained via facilitated discussions that occurred in-person, via virtual meetings, and through online surveys., (©2022 AMIA - All rights reserved.)

Purpose: California Senate Bill (SB) 1254 (effective January 1, 2019) requires pharmacy staff at acute hospitals with more than 100 beds to obtain a medication profile for high-risk patients upon hospital admission. This multicenter study sought to evaluate the statewide impact of California SB 1254 by capturing the errors intercepted and harm prevented as a result of the passage of the bill., Methods: This was a multicenter, prospective, observational study conducted at 11 hospitals in California for 6 consecutive weeks between January 2020 and March 2020. Participating sites captured medication history errors identified among high-risk patients using organization-specific criteria. Errors were categorized by type and ranked for severity of potential or actual harm based on the modified National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) categories., Results: Study sites had an average daily census of 180 to 800 patients. Approximately 94% (n = 2,554) of medication histories conducted disclosed at least 1 error. Approximately 54% (n = 1,474) of histories disclosed at least 1 serious or potentially life-threatening error. Approximately 6 errors were identified and prevented per patient (95% CI, 5.62-6.01 errors per patient), and 1 in 4 errors (25%) was categorized as potentially serious or life-threatening., Conclusion: Among high-risk patients, pharmacy-led medication histories significantly reduced medication errors. If not intercepted, these errors would have likely resulted in substantial morbidity and mortality. Future research should evaluate opportunities to standardize high-risk criteria to support patient prioritization and allocation of resources., (© American Society of Health-System Pharmacists 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The accuracy and timeliness of documenting a medication history is an important aspect to ensure appropriate medication reconciliation during transitions of care. Surgical patients often have their medication history recorded just moments before surgery which may be rushed, incomplete or missed entirely. Between January and May 2020, 76.7% of surgical patients admitted to our institution had a medication history completed by a pharmacist prior to surgery., Objective: The objective of this work is to improve the pharmacist medication history completion rates for pre-surgical patients before surgery by integrating pharmacist-led medication histories into the pre-operative pathway., Methods: Through interdisciplinary collaboration, the pre-operative pathway for surgical patients was evaluated for opportunities to complete medication histories days prior to their scheduled procedure. Plan-Do-Study-Act (PDSA) cycles were utilized to make incremental improvements in practice., Interventions: Through an iterative process, the pathway for cardiovascular surgery (CVS) patients was modified to include a scheduled pharmacist phone appointment in the days leading up to their surgical procedure. Utilizing these phone appointments, pharmacists complete patient medication history reviews and share a feedback loop to cardiovascular and peri-operative health care providers., Results: The iterative PDSA cycles revealed challenges to completing pre-surgical medication history calls without advance notice. Patient responsiveness to pre-surgical medication history calls improved with the incorporation of scheduled phone appointments. Between January 18 and May 31, 2021, pharmacists completed 359 of 376 scheduled CVS appointments (95.5%), improving the medication history completion rates for cardiovascular surgery patients from 84.8 to 93.0% (p = 0.000025). The completion rate for all surgical patients also improved from 76.7 to 85.1% (p < 0.00001)., Conclusions: Incorporating scheduled pharmacist medication history appointments as a part of the pre-operative pathway was shown to expand the capacity for pharmacists to complete medication histories for patients prior to surgery. By reducing pharmacist workload on the morning of surgery, fewer patients were admitted to surgery without having their medication history reviewed by pharmacy. Future investigation should be considered to evaluate the impact on patient outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Aim: Verifying and reviewing a patients medication list can detect and reduce drug related problems (DRPs). However little is known about its effects in patients using oral chemotherapy. The aim of this study was to evaluate the impact of these interventions and the adapted Medication Appropriateness Index (aMAI) as a tool to carry out a medication review., Methods: A case-control study was carried out. The hospital pharmacist performed a medication reconciliation and medication review, using the aMAI tool, in 54 patients starting oral chemotherapy. Discrepancies, DRP's and associated pharmaceutical interventions were reported via the electronic patient record (EPR). After one month, the acceptance rate was measured and the aMAI score recalculated. Kappa statistics were used to test intra- and interrater reliability., Results: The medication list in the EPR was incomplete in 74,1% of patients with an average of 2.4 errors per patient. After medication review, the aMAI score decreased significantly from 7.2 to 5.4 (SD  =  4,7; p <0.001), indicating an improvement in the appropriateness of the drugs patients were taking. Acceptance rates were 41,4% and 53,2% for advices resulting from medication reconciliation and medication review respectively. Kappa values of 0.90 and 0.70 respectively indicate good intra- and interrater reliability., Discussion and Conclusion: The study shows that medication reconciliation can identify and address discrepancies. Furthermore, medication review seems to ensure that drug treatment better meets patient needs. The aMAI was a reliable tool. Future research will have to determine the clinical relevance of these interventions.

Background: During transitions of care, including hospital discharge, patients are at risk of drug-related problems (DRPs)., Aim: To investigate the impact of pharmacist-led services, specifically medication reconciliation at admission and/or interprofessional ward rounds on the number of DRPs at discharge., Method: In this retrospective, single-center cohort study, we analyzed routinely collected data of patients discharged from internal medicine wards of a regional Swiss hospital that filled their discharge prescriptions in the hospital's community pharmacy between June 2016 and May 2019. Patients receiving one of the two or both pharmacist-led services (Study groups: Best Care = both services; MedRec = medication reconciliation at admission; Ward Round = interprofessional ward round), were compared to patients receiving standard care (Standard Care group). Standard care included medication history taken by a physician and regular ward rounds (physicians and nurses). At discharge, pharmacists reviewed discharge prescriptions filled at the hospital's community pharmacy and documented all DRPs. Multivariable Poisson regression analyzed the independent effects of medication reconciliation and interprofessional ward rounds as single or combined service on the frequency of DRPs., Results: Overall, 4545 patients with 6072 hospital stays were included in the analysis (Best Care n = 72 hospital stays, MedRec n = 232, Ward Round n = 1262, and Standard Care n = 4506). In 1352 stays (22.3%) one or more DRPs were detected at hospital discharge. The combination of the two pharmacist-led services was associated with statistically significantly less DRPs compared to standard care (relative risk: 0.33; 95% confidence interval: 0.16, 0.65). Pharmacist-led medication reconciliation alone showed a trend towards fewer DRPs (relative risk: 0.75; 95% confidence interval: 0.54, 1.03)., Conclusion: Our results support the implementation of pharmacist-led medication reconciliation at admission in combination with interprofessional ward rounds to reduce the number of DRPs at hospital discharge., (© 2022. The Author(s).)