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.