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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 (508).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [508]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“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]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“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]
Experimental — accuracy not yet measuredIn the citing paper
“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]
In the citing paper
“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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Galanis, T., Orapallo, D., Yenser, H., & Merli, G. (2024) · Springer eBooks · doi:10.1007/978-3-030-70904-4_35-1
Urru, S. A. M., Masucci, S., Baldo, P., Gallo, U., Schincariol, P., Silimbani, P., Vecchia, S., & Damuzzo, V. (2025) · Journal of Oncology Pharmacy Practice · doi:10.1177/10781552251351325
Machine learning for medication error detection: a scoping review protocolPreprint
Hêche, F., Yazdani, A., Ferdowsi, S., Kabak, R., Mu, G., & Teodoro, D. (2025) · medRxiv · doi:10.1101/2025.08.06.25333103
“Various strategies have been explored to mitigate these preventable events [27, 28], including medication reconciliation [29, 30], staff training [31], the adoption of automated drug administration systems [32], or the development of packaging and labeling guidelines to reduce the risk of confusion…”
Piecing together fragmented care: An evaluation of a pharmacy-driven transitions-of-care service
Ferrari, H. M., MacDonald, N. C., Bott, B., El-Khoury, C., & Martirosov, A. L. (2025) · American Journal of Health-System Pharmacy · doi:10.1093/ajhp/zxaf281
Kullar, N., Tibb, I., Lam, A., Elliott, R. A., Ting, C., & Taylor, S. E. (2025) · Journal of Pharmacy Practice and Research · doi:10.1002/jppr.70048
“2 Systematic reviews have shown that pharmacist-led medication reconciliation reduces the risk of medication errors 4,8 and may, when combined with other strategies (e.g. patient education and follow up), prevent adverse outcomes including unplanned hospital readmission.”
Assadi, R. A., Beshir, S. A., Toufiq, O., Castell, S. B., Diab, M. J., & Gulam, S. M. (2025) · PLoS ONE · doi:10.1371/journal.pone.0337233
Evaluation of Multidisciplinary Medication Reconciliation in Elderly Chemotherapy Patients
Fu, J., Xiao, H., Zhou, X., & Dang, X. (2025) · Clinical Medicine Research · doi:10.11648/j.cmr.20251406.11
Chen, K.-L., & Huang, Y. (2025) · Critical Public Health · doi:10.1080/09581596.2025.2598701
“…pharmacist-led interventions, focusing on medication reconciliation (MedRec). although MedRec has well-documented benefits (herledan et al., 2020; Mekonnen et al., 2016; Mueller et al., 2012) and has been designated as a National Patient safety Goal since 2005 (Mueller et al., 2012), our…”
Stolldorf, D. P., Ridner, S. H., Vogus, T. J., Roumie, C. L., Schnipper, J. L., Dietrich, M. S., Schlundt, D. G., & Kripalani, S. B. (2021) · Figshare · doi:10.6084/m9.figshare.14767372
Yahya, F., Nazar, H., & Hadi, M. A. (2022) · Figshare · doi:10.6084/m9.figshare.21435398
Yahya, F., Nazar, H., & Hadi, M. A. (2022) · Figshare · doi:10.6084/m9.figshare.21435395
Kamaludin, R. S., Tao, C. C., Oh, H. L., Yee, C. P., Yan, T. W., Yee, C. W., Wei, N. L., & Teoh, L. R. (2025) · Journal of Pharmaceutical Policy and Practice · doi:10.1080/20523211.2025.2604308
“…out medication reconciliation during patients’ admission and discharge target the most vulnerable points, as these are the points where unintentional medication discrepancies and information miscommunication could occur (American Society of Health-System Pharmacists, 2013; Mekonnen et al., 2016).”
InfluentialMaathuis, J., Veldhuis, A., Egbers, J. B., Geerdink, J., Karapinar‐Çarkit, F., van den Bemt, P. M. L. A., Hulshof, E. C., & Kingma, J. S. (2026) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-025-02076-x
Sales, L., Cardoso, A. F., Araujo, B. Z. R., & de Jesus, E. H. (2026) · Nursing Reports · doi:10.3390/nursrep16010022
“These findings align with previous reports identifying medication reconciliation and integration of clinical decision support as persistent weak points in hospital medication safety systems [22–24].”
Diradourian, L., de Cursay, C. L., Sterpu, R., Dumenil, A.-S., Fior, R., Eychenié, H., & Roy, S. (2026) · Le Pharmacien Clinicien · doi:10.1016/j.phacli.2025.12.011
Machine learning for medication error detection: a scoping reviewPreprint
Hêche, F., Ferdowsi, S., Yazdani, A., Sansaloni-Pastor, S., & Teodoro, D. (2026) · Research Square · doi:10.21203/rs.3.rs-8919709/v1 · Cited by 1
Preadmission Medication Data Completeness in External Referrals to a Rehabilitation Unit
Bou, S., Klumpp, H., Kozlowski, A., & Espinoza, S. (2026) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000002990
Althiyabi, S. F., Alzaidi, A. A., Asiri, A. S. M., AlGhamdi, S. M., Alwuthaynani, T. D., Al-Thopity, A. M., Azyabi, M. M., Alkhaldi, A. H., Alkhaldi, N. S., Almalki, Y. A. H., et al. (2025) · Journal of Clinical Practice and Medical Research · doi:10.59324/jcpmr.2025.1(2).06
Medication Management Strategies at Hospital Admission: A Systematic Review and Meta‐Analysis
Emadi, T., Yiu, C. H., Liu, S., Tang, D., Yeung, K. W. C. M., Baysari, M. T., Budgeon, C. A., Carter, S. R., Criddle, D., Fleming, C., et al. (2026) · Clinical and Translational Science · doi:10.1111/cts.70586
Fritz, K. S., Helm, P., Tobias, D., Semmler, J., Siaplaouras, J., Apitz, C., & Pfitzer, C. (2026) · Journal of Clinical Medicine · doi:10.3390/jcm15124802
“Several studies have demonstrated the beneficial impact of clinical pharmacists in pediatric care: A systematic review and meta-analysis reported that pharmacist-led interventions significantly reduce medication error rates in hospitalized children [25].”
Guerreiro, M. P., & Paulino, E. (2026) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-026-02177-1
“Clinical pharmacists play a fundamental role in ensuring that digital transformation translates into safer medicines use, continuity of care, improved communication and better patient outcomes [12–14].”
Stockton, W., & Morphew, T. (2026) · Journal of Pharmacy Technology · doi:10.1177/87551225261458664
Balikubiri, H., Kemp, A., Andrade, A. Q. D., & Roughead, E. E. (2026) · American Journal of Health-System Pharmacy · doi:10.1093/ajhp/zxag218
Limmen, B., van Broekhuizen, J., Essink, R. T. G. M., Dalem, J. D. R.-V., van Eikenhorst, L., van den Bemt, P. M. L. A., & Karapinar‐Çarkit, F. (2026) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-026-02189-x
The Pharmacy Profession and the Sustainable Development Goals
Peletidi, A. (2026) · Elsevier eBooks · doi:10.1016/b978-0-443-26472-6.00045-0
Organizational complexity of prolonged multiprofessional pharmacotherapy in chronic diseases
Vizeva, M., Vizev, S., Mihaylov, R., & Hayvazov, E. (2026) · Pharmacia · doi:10.3897/pharmacia.73.e203259
Metadata
- 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
- Health Sciences › Health Professions › Pharmacy › Pharmacy and Medical Practices
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › 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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