Pharmacy-led medication reconciliation programmes at hospital transitions: A systematic review and meta-analysis.
Open accessAbstract
WHAT IS KNOWN AND OBJECTIVE: Medication reconciliation is recognized as an important tool for the prevention of medication discrepancies and subsequent patient harm at care transitions. However, there is inconclusive evidence as to the impact of medication reconciliation at hospital transitions overall, as well as pharmacy-led medication reconciliation services. This review sought to evaluate the impact of pharmacy-led medication reconciliation interventions on medication discrepancies at hospital transitions and to categorize these interventions as single transition interventions or multiple transitions interventions. METHODS: PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO databases, inclusive from inception to December 2014, were searched. Included studies were published studies in English that compared the effectiveness of pharmacy-led medication reconciliation interventions to usual care and that aimed to assess medication discrepancies at hospital transitions. 'Usual care' was defined as any care where targeted medication reconciliation was not undertaken as an intervention, or if an intervention was conducted, it was not provided by a pharmacist/pharmacy technician. RESULTS AND DISCUSSION: Nineteen studies which involved a total of 15 525 adult patients were included. Eleven studies were randomized controlled trials. Overall, pharmacy-led medication reconciliation intervention usually revealed a trend towards reduction in medication discrepancies, compared with usual care. Seventeen studies involving 18 medication reconciliation interventions targeting the various transitions (admission, 9; discharge, 4; and multiple transitions, 5) were included in the meta-analysis. Compared with usual care, single medication reconciliation interventions at transitions in care (either admission or discharge) showed a significant reduction of 66% in patients with medication discrepancies (RR 0·34; 95% CI: 0·23-0·50) in favour of the intervention. There was no difference between groups for interventions targeting multiple transitions (RR 0·88; 95% CI: 0·77-1·02). Subgroup analyses confined to RCTs showed that there were no differences for target of transition (admission vs. discharge), type of intervention (multifaceted intervention vs. medication reconciliation) and setting (single centre vs. multicentre), nor pharmacists vs. pharmacy technicians (non-RCTs only). Importantly, medication discrepancies of higher clinical impact were more easily identified through pharmacy-led interventions than with usual care. WHAT IS NEW AND CONCLUSION: Pharmacy-led medication reconciliation interventions were found to be an effective strategy to reduce medication discrepancies, and had a greater impact when conducted at either admission or discharge but were less effective during multiple transitions in care. Further studies that are designed to assess the impact of the involvement of pharmacy technicians in medication reconciliation are also needed.
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No differential effect was observed in the a priori sepsis subgroup of 1,689 patients in the STARRT-AKI trial.
“No differential effect was observed in the a priori sepsis subgroup of 1,689 patients (508).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [508]
The Effect of interventions section (p. 10) discusses subgroups of medication-reconciliation studies, not sepsis patients in the STARRT-AKI trial. Searches for STARRT-AKI, sepsis, and the 1,689-patient subgroup found no passage addressing the attributed claim. (LLM, conf=0.78)
Experimental — accuracy not yet measuredThe STARRT-AKI trial demonstrated no difference in mortality between an accelerated strategy of renal replacement therapy and a standard strategy.
“The trial, which randomized 3,000 participants, demonstrated no difference in mortality in those allocated to an accelerated strategy of RRT compared with those allocated to a “standard” strategy.”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [508]
The Discussion (p. 12) concerns pharmacy-led medication reconciliation and medication discrepancies, not renal replacement therapy. Searches for STARRT-AKI, accelerated versus standard RRT, mortality, and 3,000 participants found no passage addressing the trial or its results. (LLM, conf=0.76)
Experimental — accuracy not yet measuredStudies of tools employed to promote shared decision making in patients with other serious illnesses show improved patient knowledge and awareness of treatment options.
“Studies of tools employed to promote SDM in patients with other serious illnesses show improved patient knowledge and awareness of treatment options (595).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [595]
The Characteristics of included studies (p. 2) describes medication-reconciliation programmes, and the Effect of interventions (p. 4) reports medication errors and discrepancies. Searches for shared decision making, decision aids, patient knowledge, and treatment options found no passage reporting the claimed improvement. (LLM, conf=0.76)
Experimental — accuracy not yet measuredTransfer from ICU to general floor and hospital discharge are vulnerable periods with high frequency of medication errors and information loss.
“Transfer from ICU to general floor and discharge from the hospital are both vulnerable periods for patients, with high frequency of medication errors and information loss [596–602].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [598]
Medication reconciliation has been associated with fewer medication errors and may help reduce hospital readmission.
“Medication reconciliation has been associated with fewer medication errors [598, 612] and may help reduce hospital readmission [613, 614].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [598]
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- Authors
- Mekonnen, A. B., McLachlan, A. J., & Brien, J.-A. E.
- Affiliations
- The University of Sydney (AU)
- Corresponding author
- Mekonnen, Alemayehu B.
- Venue
- Journal of Clinical Pharmacy and Therapeutics
- Publisher
- Wiley
- Published
- 2016-02-23
- Volume
- 41
- Issue
- 2
- Pages
- 128-144
- ISSN
- 0269-4727 (ISSN-L)
- OpenAlex
- W2274951248
- Cited by
- 309
- References
- 45
- Citations by year
- 2026: 28 · 2025: 19 · 2024: 26 · 2023: 26 · 2022: 29 · 2021: 40 · 2020: 36 · 2019: 30 · 2018: 43 · 2017: 20 · 2016: 12
- FWCI
- 3.52
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Clinical Pharmacy and Therapeutics (publishedVersion)
- PubMed (publishedVersion)
- Own your potential (DEAKIN) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Pharmacology › Pharmacy and Medical Practices
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Keywords
- medication reconciliation, hospital transition, medication discrepancies, pharmacist involvement, patient safety, hospitalization, hospital discharge, care transitions, medication errors, pharmacy technicians, multicomponent intervention, usual care
- MeSH terms
- Hospitals, Humans, Patient Admission, Patient Discharge, Patient Transfer, Pharmacists, Pharmacy Service, Hospital, Multicenter Studies as Topic, Randomized Controlled Trials as Topic, Medication Reconciliation
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