A retrospective review of student pharmacist medication reconciliation activities in an outpatient family medicine center
Background: Medication reconciliation in the outpatient setting is an important part of preventing medication errors, and is mandated by the Joint Commission.
Objective: To describe and quantify medication reconciliation efforts by student pharmacists in an outpatient family medicine center.
Methods: A retrospective review was conducted of medication reconciliation documentation forms completed by student pharmacists during an outpatient clinical rotation between May 2012 and April 2013. Discrepancies were defined as any lack of agreement between the medication list in the electronic medical record and the patient reported regimen. Descriptive statistics were used to report results.
Results: A total of 557 medication reconciliation documentation forms from 12 student pharmacists were reviewed. The average number of medications per patient interviewed was 9 (range 0-25). A total of 1,783 medication discrepancies were found with an average of 3.2 discrepancies per patient. An additional 272 medication allergy discrepancies were identified. The most common discrepancy was medications the patient was no longer taking (37.3%, n=766). The second most common discrepancy was over-the-counter and herbal medications that had not been added to the medication list (16.2%, n=335). Patient counseling was documented 159 times during the medication reconciliation process.
Conclusions: Medication reconciliation by student pharmacists in an outpatient family medicine center resulted in the identification of many discrepancies in medication lists in an electronic health record. Student pharmacists also documented and clarified medication allergies and performed patient counseling.
2. Bourgeois FT, Shannon MW, Valim C, Mandl KD. Adverse drug events in the outpatient setting: an 11-year national analysis. Pharmacoepidemiol Drug Saf. 2010;19(9):901-910. doi: 10.1002/pds.1984
3. Nelson KM, Talbert RL. Drug-Related Hospital Admissions. Pharmacotherapy. 1996;16(4):701-707.
4. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
5. Institute of Medicine. Preventing Medication errors: quality chasm series. Washington, DC: National Academy Press; 2006.
6. Bedell SE, Jabbour S, Golberg R, Glaser H, Gobble S, Young-Xu Y, Graboys TB, Ravid S. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med. 2000 Jul 24;160(14):2129-2134.
7. Orrico KB. Sources and types of discrepancies between electronic medical records and actual outpatient medication use. J Manag Care Pharm. 2008;14(7):626-631.
8. Wagner MM, Hogan WR. The accuracy of medication data in an outpatient electronic medical record. J Am Med Inform Assoc. 1996;3(3):234-244.
9. Stewart AL, Lynch KJ. Identifying discrepancies in electronic medical records through pharmacist medication reconciliation. J Am Pharm Assoc (2003). 2012;52(1):59-66. doi: 10.1331/JAPhA.2012.10123
10. Peyton L, Ramser K, Hamann G, Patel D, Kuhl D, Spraybery L, Steinhauer B. Evaluation of medication reconciliation in an ambulatory setting before and after pharmacist intervention. J Am Pharm Assoc (2003). 2010;50(4):490-495. doi: 10.1331/JAPhA.2010.09055
11. Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm J Qual Patient Saf. 2007;33(5):286-292.
12. American Society of Health-System Pharmacist (AHSP) Council on Pharmacy Practice. ASHP Statement on the pharmacist’s role in medication reconciliation. Am J Health Syst Pharm. 2013;70(5):453-456. doi: 10.2146/sp120009
13. Yusuff KB, Tayo F, Aina BA. Pharmacists’ participation in the documentation of medication history in a developing setting: An exploratory assessment with new criteria. Pharm Pract (Granada). 2010;8(2):139-145.
14. Mergenhagen KA, Blum SS, Kugler A, Livote EE, Nebeker JR, Ott MC, Signor D, Sung, S, Yeh J, Boockvar KS. Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events. Am J Geriatr Pharmacother. 2012;10(4):242-250. doi: 10.1016/j.amjopharm.2012.06.001
15. Lancaster JW, Grgurich PE. Impact of student pharmacists on the medication reconciliation process in high-risk hospitalized general medicine patients. Am J Pharm Educ. 2014;78(2):34. doi: 10.5688/ajpe78234
16. Andrus MR. Student pharmacist initiated medication reconciliation in the outpatient setting. Pharm Pract (Granada). 2012;10(2):78-82.
17. Ernst ME, Brown Gl, Klepser JB, Kelly MW. Medication discrepancies in an outpatient electronic medical record. Am J Health Syst Pharm. 2001;58(21):2072-2075.
The authors hereby transfer, assign, or otherwise convey to Pharmacy Practice: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print pr epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.