Pharmacist-Led Discharge Reconciliation Reduces Orthopedic Medication Errors

Pharmacist-led medication reconciliation and patient counseling were associated with significantly reduced medication errors after discharge from orthopedic surgery, according to a study in Scientific Reports.¹ Researchers’ findings support the belief that pharmacists can be key health care team members for patients undergoing orthopedic surgery.

“Medication errors during transitions of care remain a significant patient safety concern, particularly in surgical settings where medication regimens are frequently modified,” wrote the authors of the study. “In orthopedic populations, 88.9% of inpatients were reported to experience at least one medication error upon admission, with a median of 6 errors per patient; 8.1% experienced adverse events, including moderate-consequence events.”

The newly published study, conducted over a 7-month period, examined the impact of integrating a clinical pharmacy service during the critical discharge transition. This randomized controlled trial involved 178 adult patients who were being discharged from an orthopedic surgery ward with at least one prescribed medication.¹

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In the control group, patients received standard discharge care, where physicians and nurses performed reconciliation and counseling. In the intervention group, a pharmacy resident delivered a comprehensive, multicomponent service consisting of formal medication reconciliation, detailed home-medication reviews, verification of regular chronic therapies, tailored discharge counseling, and a follow-up phone call 3 days post-discharge.

The results of the trial reveal a striking difference in medication safety. Thirty days after discharge, researchers identified a total of 40 unintended medication discrepancies among the study participants.¹

In the control group, 28.1% of patients experienced at least 1 unintended discrepancy, whereas only 4.5% of those in the pharmacist-led intervention group did. Furthermore, the mean number of discrepancies per patient was reduced from 0.43 to just 0.05.

The most frequent errors identified were commissions (35%), followed by omissions (30%), and incorrect therapy durations (17.5%). Crucially, 10% of these discrepancies were categorized as potentially serious, involving high-alert medications such as enoxaparin, rivaroxaban, apixaban, and tramadol, where omissions could have led to catastrophic events like deep vein thrombosis or pulmonary embolism.¹

This reduction in post-discharge errors is particularly relevant to hospital pharmacists, who understand the unique challenges of orthopedic patient care. Orthopedic surgery patients are immediately placed into high-risk categories due to prolonged immobilization, necessitating aggressive venous thromboembolism prophylaxis, complex pain management regimens, and specialized antibiotic cover.²

In addition to direct clinical benefits, having dedicated orthopedic pharmacists in permanent, nonrotational roles fosters stronger multidisciplinary collaboration, allowing pharmacists to carry out strategic pharmacoeconomic evaluations and lead institutional antimicrobial and opioid stewardship initiatives.

By proactively screening discharge prescriptions, resolving dosing issues for high-risk patients with comorbidities like chronic kidney disease or Parkinson disease, and coordinating with medical teams, orthopedic pharmacists prevent discharge delays that can back up entire surgical wards.³

Furthermore, patient education remains a key mechanism through which pharmacists drive down clinical risks. In a prospective feasibility study on patient information pathways in France, post-operative pharmacist interviews and accompanying educational booklets dramatically improved patient knowledge regarding their prosthetic joints and discharge prescriptions, raising correct responses on essential safety questions from 70% to 91%.⁴

This educational reinforcement is vital, as the current study found that 60% of discharge discrepancies were primarily caused by gaps in patient knowledge. When clinical pharmacists provide structured counseling, patients report significantly higher levels of satisfaction and a clearer understanding of their medications upon leaving the hospital.¹

These local findings align closely with broader international evidence. A systematic review published in the American Journal of Health-System Pharmacy evaluated pharmacist interventions in perioperative settings across 19 studies involving more than 7000 patients.⁵

The review concluded that pharmacist-led clinical care is associated with optimized drug therapies, significantly improved post-operative pain control, and marked reductions in venous thromboembolism, surgery-related stress ulcers, and post-operative nausea and vomiting. The systematic review also noted that complex, multi-component interventions spanning the entire surgical journey are the most effective.

By standardizing these pharmacist-driven interventions, hospitals can bridge critical care transitions, safeguard vulnerable surgical patients, and establish the clinical pharmacist as an indispensable pillar of the orthopedic care team.

“In this single-center, open-label randomized controlled trial, pharmacist-led medication reconciliation and patient counseling at discharge were associated with a significant reduction in unintended medication discrepancies among orthopedic surgery patients,” concluded the authors of the current study.¹ “These findings suggest that integrating pharmacists into discharge processes may enhance medication safety and warrant confirmation in larger and more diverse populations.”

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REFERENCES

1. Diab S, Karaoui LR, Hussein AH, et al. Pharmacist-led medication reconciliation upon discharge from the orthopedic surgery department. Sci Rep. June 6, 2026. doi:10.1038/s41598-026-55819-9

2. Nguyen VT. Orthopaedic pharmacy: more than a rotational role. J Pharm Pract Res. 2018;48(6):581-582. doi:10.1002/jppr.1490

3. Beavis F. “Pharmacy plays a vital role in maintaining patient flow and efficiency of discharges” – a day in the life of an orthopaedic pharmacist. The Pharmaceutical Journal. April 12, 2021. Accessed August 10, 2026. https://pharmaceutical-journal.com/article/news/pharmacy-plays-a-vital-role-in-maintaining-patient-flow-and-efficiency-of-discharges-a-day-in-the-life-of-an-orthopaedic-pharmacist

4. Tortolano L, Misandeau Q, Inouri T, et al. Patient information pathway in orthopedic surgery: roles of ERAS and pharmacists. Orthop Traumatol Surg Res. 2023;109(8):103576. doi:10.1016/j.otsr.2023.103576

5. Naseralallah L, Koraysh S, Alasmar M, et al. Effect of pharmacist care on clinical outcomes and therapy optimization in perioperative settings: a systematic review. AJHP. 2024;82(1):44-73. doi:10.1093/ajhp/zxae177