The pharmacist’s role in medication reconciliation

Gathering an accurate medication history for hospital patients is definitely a team effort shared by pharmacists, physicians, and nurses. To be successful, somebody has to take ownership of the process to monitor the medication reconciliation. The pharmacist must champion this process for it to work smoothly.

In the hospital

Hospitalists, attending physicians, medical residents, and interns all recognize how important it is to collect an accurate medication history and ensure precise medication reconciliation.

Hospitals should develop a clearly defined workflow for pharmacists and physicians to obtain and reconcile medication histories. Medication reconciliation, effectively conducted, will provide an accurate discharge medication list.

The electronic medical record system will maintain the medication histories; if patients are readmitted, this information will be readily available to the emergency department. However, the record must be reviewed and updated by clinicians.

In the community

The pharmacist in the community setting, whether it be in a chain store, an independent pharmacy, a big-box operation, a supermarket, or a hospital ambulatory care apothecary, will become involved in this process as well.

The hospital’s clinical pharmacist may rely on the community pharmacist for an accurate and updated list of the medications currently prescribed to the patient. In most cases, the primary care physician has an accurate record of the patient’s medications and will provide the patient with a printout, using the NextGen program. It is imperative for the patient to carry this list with him or her at all times - especially when being treated by a specialist or an emergency department clinician.

It is then up to the attending physician to determine which home medications the inpatient will continue taking while admitted, and which, if any, should be changed upon discharge.

Three types of meds

There are three major categories of medications that an inpatient can be prescribed during the admission process.

• Ÿ The first group comprises the medications used to treat the symptoms that occasioned the admission. If a patient is admitted for bronchial pneumonia, he or she is usually given aggressive intravenous antibiotic therapy. If a patient presents with septic shock, therapy with vasopressors is usually initiated.

• Ÿ The second group of medications includes those employed to prevent adverse events, such as heparin or enoxaparin used for prophylaxis against a DVT. Low-dose aspirin also falls into this category. Notice that heparin, norepinephrine, and vancomyin are not included in the patient’s home medication reconciliation list.

• Ÿ The third category of medications prescribed for the inpatient includes the home medications. This is the list of medications that the patient takes on a daily basis. It should be provided to the emergency department physician upon admission to the hospital.

The attending physician or hospitalist will then determine which of these medications should continue and which should be stopped while the patient is a hospital inpatient. If intravenous metoprolol is prescribed, the physician might want to discontinue the patient’s PO carvedilol to prevent duplication of therapy. PO OxyContin and all combinations may be discontinued while the patient is being given IV morphine following a surgical procedure.

Teaching hospital

When pharmacists, retail or hospital, work in tandem with medical residents in a community teaching hospital, the collaboration should lead to a reduction in readmissions, emergency department visits, and hospital costs.

Complete and accurate medication reconciliation by the entire healthcare team will increase overall accuracy of the admission process.