Impact of an integrated medication reconciliation model led by a hospital clinical pharmacist on the reduction of post-discharge unintentional discrepancies.

WHAT IS KNOWN AND OBJECTIVE: There is no optimal standardized model in the transfer of care between hospitals and primary healthcare facilities. Transfer of care is a critical point during which unintentional discrepancies, that can jeopardize pharmacotherapy outcomes, can occur. The objective was to determine the effect that an integrated medication reconciliation model has on the reduction of the number of post-discharge unintentional discrepancies. METHODS: A randomized controlled study was conducted on an elderly patient population. The intervention group of patients received a medication reconciliation model, led entirely by a hospital clinical pharmacist (medication reconciliation at admission, review and optimization of pharmacotherapy during hospitalization, patient education and counselling, medication reconciliation at discharge, medication reconciliation as part of primary health care in collaboration with a primary care physician and a community pharmacist). Unintentional discrepancies were identified by comparing the medications listed on the discharge summary with the first list of medications prescribed and issued at primary care level, immediately after discharge. The main outcome measures were incidence, type and potential severity of post-discharge unintentional discrepancies. RESULTS AND DISCUSSION: A total of 353 patients were analysed (182 in the intervention and 171 in the control group). The medication reconciliation model, led by a hospital clinical pharmacist, significantly reduced the number of patients with unintentional discrepancies by 57.1% (p < 0.001). The intervention reduced the number of patients with unintentional discrepancies associated with a potential moderate harm by 58.6% (p < 0.001) and those associated with a potential severe harm by 68.6% (p = 0.039). The most common discrepancies were incorrect dosage, drug omission and drug commission. Cardiovascular medications were most commonly involved in unintentional discrepancies. WHAT IS NEW AND CONCLUSION: The integrated medication reconciliation model, led by a hospital clinical pharmacist in collaboration with all health professionals involved in the patient's pharmacotherapy and treatment, significantly reduced unintentional discrepancies in the transfer of care.

Clinical knowledge of community pharmacists in Croatia for detecting drug-related problems.

Background Drug-related problems (DRPs) interfere with patient's health outcomes and have a negative impact on healthcare resources. Successful management of DRPs is an essential part of pharmaceutical care. Pharmacists should have adequate clinical knowledge in order to effectively implement pharmaceutical care and manage DRPs. Objective To determine the clinical knowledge of community pharmacists in Croatia to detect and resolve DRPs. Method A sample of 302 community pharmacists have anonymously and voluntarily completed the validated survey-based clinical knowledge measurement tool. For each completed survey, all statements were scored individually, and a total score was calculated. The lowest possible total score was 0 and the highest was 80. Higher survey score indicates a higher level of clinical knowledge to detect and resolve a DRP. Results All community pharmacists had a mean score of 45.5 ± 8.6, while pharmacists from a pharmacy chain with mandatory education had a higher mean score of 50.2 ± 6.5. Multivariate linear regression revealed that only additional education (ß = 0.272, p < 0.001) is associated with a higher mean score, while age and gender have no influence on the survey score. Conclusion Additional education of community pharmacists could increase their clinical knowledge to detect and resolve DRPs.