Pharmacy student-assisted medication reconciliation: Number and types of medication discrepancies identified by pharmacy students

Main Article Content


Medication Reconciliation, Students, Pharmacy, Professional Competence, Pharmaceutical Services, Medical History Taking, Hospitalization, Pharmacists, Workforce, Cross-Sectional Studies, Australia


Background: Medication reconciliation aims to prevent unintentional medication discrepancies that can result in patient harm at transitions of care. Pharmacist-led medication reconciliation has clear benefits, however workforce limitations can be a barrier to providing this service. Pharmacy students are a potential workforce solution.

Objective: To evaluate the number and type of medication discrepancies identified by pharmacy students.

Methods: Fourth year pharmacy students completed best possible medication histories and identified discrepancies with prescribed medications for patients admitted to hospital. A retrospective audit was conducted to determine the number and type of medication discrepancies identified by pharmacy students, types of patients and medicines involved in discrepancies.

Results: There were 294 patients included in the study. Overall, 72% (n=212/294) had medication discrepancies, the most common type being drug omission. A total of 645 discrepancies were identified, which was a median of three per patient. Patients with discrepancies were older than patients without discrepancies with a median (IQR) age of 74 (65-84) vs 68 (53-77) years (p=0.001). They also took more medicines with a median (IQR) number of 9 (6-3) vs 7 (2-10) medicines per patient (p<0.001). The most common types of medicines involved were those related to the alimentary tract and cardiovascular system.

Conclusions: Pharmacy students identified medication discrepancies in over 70% of hospital inpatients, categorised primarily as drug omission. Pharmacy students can provide a beneficial service to the hospital and contribute to improved patient safety by assisting pharmacists with medication reconciliation.

Abstract 1349 | pdf Downloads 551 online appendix Downloads 61


1. The World Health Organisation. Medication without harm: Global patient safety challenge on medication safety. (Aug 10, 2020).
2. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.
3. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424-429.
4. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510-515.
5. Penm J, Vaillancourt R, Pouliot A. Defining and identifying concepts of medication reconciliation: An international pharmacy perspective. Res Social Adm Pharm. 2019;15(6):632-640.
6. Almanasreh E, Moles R, Chen TF. The medication discrepancy taxonomy (MedTax): The development and validation of a classification system for medication discrepancies identified through medication reconciliation. Res Social Adm Pharm. 2020;16(2):142-148.
7. The Australian Commission on Safety and Quality in Health Care. The National Safety and Quality Health Service Standards Second Edition. (accessed Aug 10, 2020).
8. Stark HE, Graudins LV, McGuire TM, Lee CYY, Duguid MJ. Implementing a sustainable medication reconciliation process in Australian hospitals: The World Health Organization High 5s project. Res Social Adm Pharm. 2020;16(3):290-298.
9. Mekonnen AB, McLachlan AJ, Brien JA. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open. 2016;6(2):e010003.
10. Allende Bandrés MÁ, Arenere Mendoza M, Gutiérrez Nicolás F, Calleja Hernández MÁ, Ruiz La Iglesia F. Pharmacist-led medication reconciliation to reduce discrepancies in transitions of care in Spain. Int J Clin Pharm. 2013;35(6):1083-1090.
11. Becerra-Camargo J, Martinez-Martinez F, Garcia-Jimenez E. A multicentre, double-blind, randomised, controlled, parallel-group study of the effectiveness of a pharmacist-acquired medication history in an emergency department. BMC Health Serv Res. 2013;13:337.
12. Champion HM, Loosen JA, Kennelty KA. Pharmacy Students and Pharmacy Technicians in Medication Reconciliation: A Review of the Current Literature. J Pharm Pract. 2019;32(2):207-218.
13. Sproul A, Goodine C, Moore D, et al. Quality of best possible medication history upon admission to hospital: Comparison of nurses and pharmacy students and consideration of national quality indicators. Can J Hosp Pharm. 2018;71(2):128-134.
14. Lubowski TJ, Cronin LM, Pavelka RW, Briscoe-Dwyer LA, Briceland LL, Hamilton RA. Effectiveness of a medication reconciliation project conducted by PharmD students. Am J Pharm Educ. 2007;71(5):94.
15. Lancaster JW, Grgurich PE. Impact of students pharmacists on the medication reconciliation process in high-risk hospitalized general medicine patients. Am J Pharm Educ. 2014;78(2):34.
16. Andrus MR. Student pharmacist initiated medication reconciliation in the outpatient setting. Pharm Pract (Granada). 2012;10(2):78-82.
17. National Competency Standards Framework for Pharmacists in Australia 2016. Pharmaceutical Society of Australia. (accessed Dec 20, 2020).
18. WHO Collaborating Centre for Drug Statistics Methodology. ATC classification index with DDDs, 2020. (accessed Sep 13, 2020).
19. Petrov K, Varadarajan R, Healy M, Darvish E, Cowden C. Improving Medication History at Admission Utilizing Pharmacy Students and Technicians: A Pharmacy-Driven Improvement Initiative. P T. 2018;43(11):676-684.
20. Guo Q, Guo H, Song J, et al. The role of clinical pharmacist trainees in medication reconciliation process at hospital admission. Int J Clin Pharm. 2020;42(2):796-804.
21. Canning ML, Munns A, Tai B. Accuracy of best possible medication history documentation by pharmacists at an Australian tertiary referral metropolitan hospital. Eur J Hosp Pharm. 2018;25(e1):e52-e58.