Medicines reconciliation pilot shows promise


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A new British preliminary study has supported changes to hospital protocols whereby pharmacists would provide medicines reconciliation

Pharmacist-provided medicines reconciliation within 24 hours of admission and on discharge: a randomised controlled pilot study, published in the BMJ, sought to determine the effectiveness and cost-effectiveness of a pharmacist-driven service.

“Researchers have identified unintentional error rates within hospital prescriptions on admission of between 30% and 70% and these can include omission of usual medicines, prescription of incorrect dosages and addition of medicines which have not been previously prescribed,” the authors write.

“The majority of these errors are believed to result from deficiencies in the MR process with such errors known to contribute to patient morbidity and mortality and increase the length of hospital stay.

“Consequently, within the UK, patient safety guidance issued by the National Patient Safety Agency (NPSA) and the National Institute for Health and Care Excellence (NICE) recommended that policies for MR should be implemented in hospitals for all adult patient admissions, and that pharmacy should be involved in the MR process within 24 hours of admission.”

Recent systematic reviews of hospital-based MR practices have consistently demonstrated a reduction in medicine discrepancies; but this has not been shown to cause reductions in post-discharge healthcare usage, the authors point out.

“When considering only pharmacist-led MR interventions a 19% reduction in the rate of all-cause readmissions was seen but similarly pooled data on mortality and composite readmission and emergency department (ED) visit did not find in favour of either pharmacist-led intervention or usual care.

“With the significant resources required for pharmacists to deliver MR services, it is not adequate to demonstrate reduction in errors (which may or may not result in adverse drug events), it is also important in resource limited health systems to show that such investment constitutes value for money. There is currently a recognised lack of evidence supporting the cost-effectiveness of MR interventions provided by pharmacists.”

This study therefore aimed to pilot a randomised controlled trial to examine the clinical and cost-effectiveness of pharmacy providing a full MR service on admission and at discharge.

“Nine hundred and nineteen patients were assessed for eligibility of which 224 did not meet inclusion criteria,” the authors write. “Two hundred out of 310 patients who were subsequently approached by the RA consented to take part in the study.”

Based on the pilot data, they calculated that for a full trial, 1120 patients would need to be recruited to detect a 6% reduction (a conservative assumption) in three-month unplanned readmission rates.

Such a trial was feasible, they said, suggesting that emergency rehospitalisation within three months would be the most appropriate primary outcome measure.

“The pilot study has shown that it is feasible to perform an RCT to determine the effectiveness and cost-effectiveness of a pharmacist MR within 24 hours of admission and again at discharge.

“This study has demonstrated that this form of intervention does appear to reduce medication errors at discharge, and may reduce LOS and hospital readmissions. We consider that unplanned readmission at three  months is the most suitable primary outcome measure but LOS, errors, mortality and quality of life should be captured.”

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