Pharmacist-led medication reconciliation on admission to an acute psychiatric hospital unit

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António MACEDO
M. Margarida CARAMONA
Isabel V. Figueiredo


Medication Errors, Medication Reconciliation, Patient Safety, Transitional Care


Background: Therapy management in patients suffering from mental health disorders is complex and the risks derived from changes or interruptions of treatment should not be ignored. Medication reconciliation in psychiatry may reduce medication errors and promote patient safety during transitions of care. Objective: To identify the influence of complementary information sources in the construction of the best possible medication history, and to ascertain the potential clinical impact of discrepancies identified in a medication reconciliation service. Methods: An observational study was conducted in an acute mental hospital unit, with a further validation in an internal medicine unit. Adult patients taking at least one medicine admitted in the unit were included. Patients/caregivers were interviewed upon admission and the information gathered was compared with hospital medical and shared electronic medical records. Once the best possible medication history was gathered, therapeutic information was reconciled against the prescription on admission to identify discrepancies. Potential clinical impact of medication errors was classified using the International Safety Classification. Results: During the study period, 148 patients were admitted, 50.7% females, mean age 54.6 years (SD=16.3). Collaboration of a caregiver was a needed in 74% of the interviews. In total, 1,147 drugs were considered to obtain patients’ best possible medication history. After reconciliation, 560 clinically sound intentional discrepancies were identified and 359 discrepancies required further clarification from prescribers: 84.12% “drug omission”, 5.57% “drug substitution”, 6.96% “dose change”, and 3.34% “dosage frequency change”. Potential clinical impact of these medication discrepancies was classified as: 95 mild, 100 moderate, and 29 severe medication errors. Conclusion: About 1 in three intentional discrepancies observed in a pharmacists-led medication reconciliation service required further clarification from prescribers, being 80% of them unintentional discrepancies. Results highlight the importance of the caregiver as source of information for the psychiatric patient, the relevance of analyzing shared electronic health records until 6 months before, and the need to use hospital medical records efficiently. Additionally, 29 discrepancies were classified as errors with potentially severe clinical impact. A medication reconciliation service is concluded to be feasible and necessary in a mental health unit.


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1. World Health Organization. Medication Safety in Transitions of Care. Available at:
medication-safety/TransitionOfCare.pdf?ua=1 (accessed Feb 7, 2022)
2. 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.
3. Oliveira J, Cabral AC, Lavrador M, et al. Contribution of different patient information sources to create the best possible
medication history. Acta Med Port. 2020;33(6):384-389.
4. World Health Organization (WHO); Action on Patient Safety (WHO). The High 5 Project: Standard Operating Protocol Assuring
Medication Accuracy at Transitions in Care. Available at:
high5s/h5s-sop.pdf?ua=1 (Accessed Feb 7, 2022).
5. NICE guideline. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Available
at: (accessed Feb 7, 2022).
6. Paton C, McIntyre S, Bhatti SF, et al. Medicines Reconciliation on Admission to Inpatient Psychiatric Care: Findings from a UK Quality
Improvement Programme. Ther Adv Psychopharmacol. 2011;1(4):101-110.
7. Rothschild JM, Mann K, Keohane CA, et al. Medication safety in a psychiatric hospital. Gen Hosp Psychiatry. 2007;29(2):156-
8. MARQUIS investigators - Marquis implementation manual. A guide for medication reconciliation quality improvement.
Society of Hospital Medicine. Available at:
medication_reconciliation_guide.pdf (accessed Feb 8, 2022)
9. Lertxundi U, Corcostegui B, Prieto M, et al. Medication reconciliation in psychiatric hospitals: some reflections. J Pharm Pract
Res. 2017;47(1):47-50.
10. World Health Organization: Patient Safety (WHO). Conceptual Framework for the International Classification for Patient Safety
Version 1.1. Available at: (accessed Feb 8, 2022).
11. Qu SQ, Dumay J. The qualitative research interview. Qualitative R)esearch in Account Manag. 2011;8(3):238-264. https://doi.
12. Hong CJ, Kaur MN, Farrokhyar F, et al. Accuracy and completeness of electronic medical records obtained from referring
physicians in a Hamilton, Ontario, plastic surgery practice: A prospective feasibility study. Plast Surg (Oakv). 2015;23(1):48-50.
13. 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.
14. Poornima P, Reshma P, Ramakrishnan TV, et al. Medication reconciliation and medication error prevention in an emergency
department of a tertiary care hospital. J Young Pharm. 2015;7(3):242-249.
15. Graabæk T, Terkildsen BG, Lauritsen KE, et al. Frequency of undocumented medication discrepancies in discharge letters after
hospitalization of older patients: a clinical record review study. Ther Adv Drug Saf. 2019;10:2042098619858049. https://doi.
16. Hellström LM, Bondesson Å, Höglund P, et al. Errors in medication history at hospital admission: prevalence and predicting
factors. BMC Clin Pharmacol. 2012;12:9.
17. 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. https://doi.
18. Hias J, Van der Linden L, Spriet I, et al. Predictors for unintentional medication reconciliation discrepancies in preadmission
medication: a systematic review. Eur J Clin Pharmacol. 2017;73(11):1355-1377.
19. Kukreja S, Kalra G, Shah N, et al. Polypharmacy in psychiatry: A review. Mens Sana Monogr. 2013;11(1):82-99. https://doi.

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