Proposed Topic (Most preferred): :
HA Young Investigators Session (Projects to be presented by HA staff who had joined HA for 10 years or less)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Authors (including presenting author) :
Yeo JWQ (1), Cheng YM (1), Ng V (1), Chow T (1), Li W (1)
Affiliation :
(1) Department of Pharmacy, Princess Margaret Hospital, Hospital Authority, Hong Kong SAR
Introduction :
Medication reconciliation aims to prevent medication discrepancies and enhance medication safety during transition of care. Pharmacist-led medication reconciliation service at hospital discharge was initiated in two Medicine & Geriatrics (M&G) wards in June 2022 and rolled out to eight M&G wards by December 2023.
Objectives :
This study aimed to investigate the prevalence and types of pharmacist-identified drug-related problems (DRPs) at discharge and to survey the satisfaction levels amongst doctors, nurses, and patients.
Methodology :
This study was a retrospective, single-centered study carried out in a 1700-bed acute hospital in Hong Kong. Clinical pharmacists stationed in each ward were responsible for conducting medication reconciliation services. Pharmacists would review medication history, compile an accurate list of medications the patient are taking, identify drug-related problems (DRPs) and make recommendations accordingly. Interventions were documented in a corporate electronic system using a standardized format. Medication counseling was provided to patients upon discharge. DRPs from June 2022 to August 2023 were retrieved for analysis. DRPs were classified by the simplified PCNE (Pharmaceutical Care Network Europe) classification and DRP severity was ranked based on a validated instrument published on AJHP (American Journal of Health-System Pharmacy). Evaluation surveys were conducted for doctors, nurses and patients in November 2023.
Result & Outcome :
From June 2022 to August 2023, 6765 discharge prescriptions were reviewed and 1969 DRPs were identified. The most commonly identified DRPs were inadequate drug supply (26.0%), no/incomplete drug treatment despite existing indication (26.0%), and inappropriate treatment duration (17.0%). 81.8% of DRPs were ranked significant. The top 3 drug classes involved were oral hypoglycemics and insulin (8.0%), nitrates, calcium-channel blockers and other anti-anginal drugs (6.7%), and analgesics (6.3%). 99.0% of the interventions were accepted by physicians. Survey results conducted amongst 69 doctors and nurses demonstrated that 94.2% agreed ward pharmacist helped to identify and resolve medication errors or discrepancies, and 91.3% agreed that pharmacist involvement in the medication reconciliation process helped to facilitate discharge procedures. Patient experience survey results conducted amongst 31 patients reflected that 100% agreed that bedside pharmacist counselling was able to help them improve understanding and gain confidence in managing their medications. Pharmacist-led medication reconciliation allows pharmacists to identify DRPs during transition of care. A high acceptance rate and clinical significance of pharmacist interventions were demonstrated in this study. In conclusion, medication reconciliation conducted by clinical pharmacists can decrease medication discrepancies at hospital discharge, enhance medication safety and improve continuity of care.
