Implementation and evaluation of a collaborative clinical pharmacist's medications reconciliation and charting service for admitted medical inpatients in a metropolitan hospital

Summary What is known and objective Medication errors on admission can persist throughout the episode of care and on to discharge leading to inappropriate management that can compromise patients’ care. The aim of the study was to develop, implement and evaluate the role of pharmacist‐led medication reconciliation and charting service for patients admitted to an Acute Assessment and Admission Unit via the Emergency Department in an electronic medication management environment at a metropolitan Australian hospital. Methods Following the credentialing of an experienced clinical pharmacist to perform collaborative medication charting, a prospective parallel study of medication errors was undertaken. Patients were randomly allocated to an intervention ( n = 56) or a usual care (control) ( n = 54) arm. Medication orders were charted by the medical staff in the usual care arm, whereas the pharmacist charted the medications in the intervention arm. An independent clinical pharmacist reviewed all the medication orders at 24 h after admission and errors recorded. The severity of errors was rated by a ‘blinded’ consultant physician and an independent senior pharmacist according to a standardized matrix. The potential time saving for the medical staff was investigated. A survey was conducted to assess the perception, acceptance and satisfaction of the service. Results and discussion The intervention arm (reconciliation performed by pharmacist) achieved an error reduction greater than 80%. The average error rate decreased from 4·41 to 0·52 errors per patient ( P < 0·0001) and 0·43–0·05 errors per order ( P < 0·005). The severity of the errors was also diminished. Time evaluation estimated that the pharmacist can save more than 30 min per patient for the admitting medical officers. Staff satisfaction survey indicated that the service was well received by the medical staff. What is new and conclusion A model of a collaborative clinical pharmacist reconciliation and charting service for admitted medical patients in an Australian hospital was successfully implemented. The service was well received and has shown to save medical staff time allowing them to attend to other duties. Moreover, the pharmacist charting and reconciliation service has resulted in a statistically significant reduction in medication errors.