Pharmacy-led medication is best practice

Pharmacy-led medication is best practice

Medication reconciliation involves comparing the patient’s home medication list with the medications prescribed by the prescriber at each transition of care.1.2 The goal of reconciliation is to identify and resolve discrepancies between the two, such as medication omissions, duplications, and documentation errors, and to ensure that any changes are notified to physicians.2.3 Both The Joint Commission (TJC) and the Institute for Healthcare Improvement (IHI) advocate for the completion of medication reconciliation at all transitions of care. As reported in the medical literature, incorporating these activities into routine patient care can prevent adverse events (AEs) that can impact patient outcomes.1.3 Involving the pharmacy in this process, including obtaining medication histories and completing admission and discharge reconciliation, is an important factor in designing best practices.

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Findings from the medical literature support pharmacy involvement

A body of medical literature demonstrates that pharmacy involvement in the medication reconciliation process is a cost-effective approach to optimizing patient care by preventing medication errors during transitions, facilitating communication between physicians, freeing providers more time for other patient care tasks, and reducing 30- daily receipts.4-6 Medication reconciliation is a multi-step process and includes, at a minimum, medication history acquisition, admission and discharge reconciliation.

The first step is to obtain a thorough and accurate list of the patient’s home medications, including prescription, over-the-counter, and complementary and alternative medicines. If the patient is transferred from an outside facility, the medication list may include medications received at outside hospitals or during the transfer process. Figures cited by the World Health Organization (WHO) indicate that 67% of medication histories contain at least 1 error, creating discrepancies between what the patient is ordered in hospital and how the medication is taken at home.7 Twenty-seven percent of prescribing errors can be attributed to inaccurate or incomplete home medication lists.7

Marshall et al. recently published an observational, retrospective review examining the impact of a pharmacy-driven medication history program on patient outcomes. Results demonstrated a significant reduction in patient length of stay and in-hospital mortality with fewer medication-related adverse events. An accurate patient home medication list not only reduces prescribing errors, but also facilitates more efficient admission and discharge processes.4

Admission approval is the next step in the process and involves comparing the patient’s home medication list with the medication orders placed by the prescriber. Several systematic reviews and studies have been conducted that have examined patient outcomes with pharmacy-led admission reconciliation in a variety of patient care settings. Choi et al conducted a systematic review and meta-analysis in 2019 and found that pharmacy involvement in the admission reconciliation process resulted in significant reductions in both average discrepancies per patient and potential adverse events.8 These findings were particularly noted in medically complex patients (ie, > 3 comorbidities and > 4 medications) and in those with potential adverse events related to serious or life-threatening events.8

Pediatric patients represent a particularly high-risk patient population, with up to 37% of hospitalized children experiencing medication errors and 67% having medication history discrepancies.9 Hovey et al conducted a prospective observational cohort examining pharmacist-led reconciliation of admissions and demonstrated that 22% of pharmacy interventions were found to be clinically relevant, with 8 interventions found to have likely prevented harm or death over a 90-day period.9 The investigators were also able to quantify the potential annual cost savings of $186,986.60 resulting from pharmacy participation in the admission approval process.9

Discharge approval is the final step in the process and includes a review of the patient’s home medication list, medication administration record, and medical records in the electronic health record for regimen changes during hospitalization, culminating in the creation of a discharge medication list. Published data have shown that up to 40% of patients have medication list discrepancies at discharge, posing a greater risk to patients than admission errors as they transition to the home environment without ongoing monitoring.10 Professional organizations recommend that best practice include pharmacy involvement in multidisciplinary teams managing transitions of care, as evidence has shown that pharmacy involvement reduces post-discharge and readmission emergency department visits and is more cost-effective than other interventions.5.10

Rodrigues et al examined the impact of pharmacy-supported care transitions on 30-day readmissions.5 The authors found that pharmacy involvement in care transition activities resulted in a significant impact on 30-day readmissions, which was further increased when patient-centered follow-up (eg, phone call, home visit, clinic visit) was included. No study produced results favoring the usual care group (ie, no pharmaceutical intervention). The most common intervention was medication, which often included patient counseling.5 Investigators noted that pharmacy staff are uniquely qualified to provide reconciliation services, resulting in reduced preventable adverse drug reactions and improved medication adherence.5

In 2012, the Centers for Medicare & Medicaid Services (CMS) enacted the Hospitalization Reduction Program (HRRP) to reduce preventable readmissions and promote value-based care.6 The program penalizes hospitals with higher than expected 30-day readmission rates for specific disease states by reducing their reimbursement. In response, hospitals have developed care transition programs to improve patient outcomes and reduce readmissions, with many recognizing the role of pharmacists as medication management specialists who can optimize medication regimens, prevent medication-related problems, and facilitate safe transitions home.6

Harris et al conducted a systematic review of 123 articles evaluating the impact of pharmacy reconciliation services developed by hospitals in response to the HRRP. Just over 89% of studies demonstrated a reduction in 30-day readmissions after implementing a pharmacy-led care transition program. The 2 most impactful services included medication reconciliation and provision of medication education at discharge, for patients with a CMS HRRP diagnosis or high-risk characteristics (ie, polypharmacy, poor health literacy, >65 years, high-risk medications, recent readmission, chronic medical conditions), from who benefit the most.6

Optimizing pharmacy contributions to medication reconciliation

WHO recommends that members of the pharmacy team obtain the best possible medication history (BPMH) by thoroughly documenting all medications reported by the patient or carer and confirmed using a second source providing an external prescribing history (eg Surescripts).7 Ideally, a proactive model is followed that completes the BPMH on admission as a separate step before the prescriber enters inpatient orders.7

Allocating pharmacy resources to the task of admission and discharge reconciliation is also the best method of preventing medication-related problems, especially for medically complex patients.8 Inclusion of pharmacy technicians, students, or residents in the reconciliation process shows no difference in effectiveness.8,11 The use of pharmacy extenders (ie, pharmacy technicians, students, residents) and the use of medication-related criteria (eg, polypharmacy, high-risk medications, recent medication changes) to identify patients who benefit most from pharmacy services may be health rationales. care organizations when resources are limited.5,7,8 For added value, the pharmacy should also provide patient education, compile medication calendars, and coordinate post-discharge follow-ups.

Future efforts should focus on designing best practice models and developing service funding strategies. Hospitals can thus take advantage of the important contributions that pharmacy can make to the medication reconciliation process.


  1. Institute for Healthcare Improvement. Medication reconciliation to prevent adverse drug reactions. Accessed March 31, 2023.
  2. Greenwald JL, Halasyamani L, Greene J, et al. Ensuring that inpatient medication reconciliation is patient-centred, clinically relevant and feasible: A consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5(8):477-485. doi:10.1002/jhm.849
  3. Joint Commission. National Patient Safety Goals 2023. Accessed March 31, 2023.
  4. Marshall J, Hayes BD, Koehl J, et al. Effects of a pharmacy-driven medication history program on patient outcomes. Am J Health Syst Pharm. 2022;79(19):1652-1662. doi:10.1093/ajhp/zxac143
  5. Rodrigues CR, Harrington AR, Murdock N, et al. Effect of pharmacy-supported care transition interventions on 30-day readmissions: a systematic review and meta-analysis. Ann Pharmacother. 2017;51(10):866-889. doi:10.1177/1060028017712725
  6. Harris M, Moore V, Barnes M, Persha H, Reed J, Zillich A. Effect of pharmacy-led interventions during transitions of care on hospital readmissions: A systematic review. J Am Pharm Assoc (2003). 2022;62(5):1477-1498.e8. doi:10.1016/j.japh.2022.05.017
  7. Action on Patient Safety (High 5s) Initiative, World Health Organization. The High5s project: a standard operating protocol. Ensuring medication accuracy during transitions in care: medication reconciliation. Version 3. Published September 2014. Accessed 31 March 2023. pdf
  8. Choi YJ, Kim H. Impact of pharmacy medication reconciliation in emergency departments: A systematic review and meta-analysis. J Clin Pharm Ther. 2019;44(6):932-945. doi:10.1111/jcpt.13019
  9. Hovey SW, Click KW, Jacobson JL. The effect of a pharmacy reconciliation service on pharmacist intake at a children’s hospital. J Pediatr Pharmacol Ther. 2023; 28 (1): 36-40. doi:10.5863/1551-6776-28.1.36
  10. Fernandes BD, Almeida PHRF, Foppa AA, Sousa CT, Ayres LR, Chemello C. Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in social and administrative pharmacy, 2020;16(5):605-613. doi:10.1016/j.sapharm.2019.08.001
  11. Punj E, Collins A, Agravedi N, Marriott J, Sapey E. What is the evidence that a pharmacy team working in an acute or emergency department improves patient outcomes: A systematic review. Pharmacology Res & Perspec. 2022;10(5):e01007. doi:10.1002/prp2.1007

About the authors

Marla C. Tanski, PharmD, MPH, MS, BCPPS, is chief of clinical pharmacy at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida.

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