Transitions in Care: Medication Reconciliation in the Community Pharmacy Setting After Discharge

Abstract

Objective: To assess the feasibility of a workflow process in which pharmacists in an independent community pharmacy group

conduct medication reconciliation for patients undergoing transitions in care.

Methods: Three workflow changes were made to improve the medication reconciliation process in a group of three independent

community pharmacies. Analysis of the process included workflow steps performed by pharmacy staff, pharmacist barriers

encountered during the medication reconciliation process, number of medication discrepancies identified, and pharmacist comfort

level while performing each medication reconciliation service.

Key Findings: Sixty patient medication reconciliation services met the inclusion criteria for the study. Pharmacists were involved in all

steps associated with the medication reconciliation workflow, and were the sole performer in four of the steps: verifying discharge

medications with the pharmacy medication profile, resolving discrepancies, contacting the prescriber, and providing patient

counseling. Pharmacists were least involved in entering medications into the pharmacy management system, performing that

workflow step 13% of the time. The most common barriers were the absence of a discharge medication list (24%) and patient not

present during consultation (11%). A total of 231 medication discrepancies were identified, with an average of 3.85 medication

discrepancies per discharge. Pharmacists’ comfort level performing medication reconciliation improved through the 13 weeks of the

study.

Conclusions: These findings suggest that medication reconciliation for patients discharged from hospitals and long term care facilities

can be successfully performed in an independent community pharmacy setting. Because many medication discrepancies were

identified during this transition of care, it is highly valuable for community pharmacists to perform medication reconciliation services.