Study Design, Setting, and Participants
A prospective observational single-centre study was conducted at Second Hospital of Shanxi Medical University, a 2700-bed grade A tertiary university teaching hospital in Taiyuan, China. Medication reconciliation at hospital admission was performed in the following departments: cardiology department (15 beds provided with pharmaceutical services (PC beds)), nephrology department (10 PC beds), endocrinology department (20 PC beds), and respiratory medicine (12 PC beds) between 2019 Feb 1st and 2019 Aug 31st. Ethical approval was granted by the research ethics committee of the Second Hospital of Shanxi Medical University (ID: 2019-184).
The medication reconciliation and medication review were performed up to 48 hours after patient hospital admission. Eligible patients were adults (18 years old and above) and taking at least one home/regular medication. We excluded patients who were not able to communicate, and unwilling or unable to give informed consent.
Medication reconciliation process
In our hospital, the clinical pharmaceutical service team consisted of four full-time clinical pharmacists and eight trainees from the One-Year Clinical Pharmacist Training Program. The pharmacists involved in this study are also certificated preceptors of the National Health Commission pilot training program with more than 5 years teaching experiences. The team was trained, supervised, and managed by these clinical pharmacist preceptors, and the clinical pharmacist trainees were trained in how to take a BPMH and the standardized method of WHO High 5s protocol were applied[9].
The process of medication reconciliation on admission includes the following four steps[9]: (1) Obtain a BPMHA clinical pharmacist obtains a BPMH through extensive interviews with 48 hours by several sources, such as a patient and/or family interview, medicine vials, previous medical records, discharge medication records, outpatient pharmacy records and patient’s medication file. (2)Confirm the accuracy of the history . (3) Reconcile BPMH with prescribed medication(s) The BPMH was compared with the medication(s) ordered at admission to detect possible medication discrepancies. The medication discrepancies detected were categorized into intentional, unintentional and undocumented intentional discrepancies. And unintentional medication discrepancies without clinical justification were considered medication errors and categorized as follows: drug omission, incorrect dose, incorrect frequency, incorrect administration route, incorrect drug and incorrect drug administration time. (4) Supply accurate medications informationOnce discrepancies were discovered, each case was discussed between the pharmacists and the physician to determine whether the discrepancy was unintended and meanwhile the medication order was corrected accordingly. Right after, the UMDs were classified according to their potential to cause harm.
All UMDs were showed to the expert group consisting of four experienced clinical pharmacists on the basis of the rating mode developed by Cornish et al[19]. The impact degree of each medication discrepancy was characterized as follows: i) class 1 – discrepancies without the potential to lead to patient discomfort or clinical deterioration, ii) class 2 – discrepancies with the potential to lead to moderate discomfort or clinical deterioration, and iii) class 3 - discrepancies with the potential to cause severe discomfort or clinical deterioration. Additional patient clinical information including previous discharge records and laboratory results, were assessed as needed. All disagreements were settled and consensus was obtained for the classification of medication discrepancies.