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JOAN S. KRAMER, PHARM.D., is Clinical Research and Hospital Medicine Specialist, Department of Pharmacy; PAULA J. HOPKINS, B.S.N., M.S.N., is Adult Medical–Surgical Clinical Nurse Specialist, Department of Trauma and Surgery; and JAMES C. ROSENDALE is Data Architect, Department of Pharmacy, Wesley Medical Center (WMC), Wichita, KS. JAMES C. GARRELTS, B.S., PHARM.D., is Leader, Clinical Pharmacy Services, Via Christi Regional Medical Center, St. Francis Campus, Wichita; at the time of this study he was Manager, Critical Care Pharmacy Services and Research, Department of Pharmacy, WMC. LADONNA S. HALE, PHARM.D., is Associate Professor, Department of Physician Assistant, College of Health Professions, Wichita State University, Wichita, and Clinical Pharmacist, Department of Pharmacy, WMC. TINA M. NESTER, PHARM.D., is Internal Medicine Clinical Specialist, Department of Pharmacy; PATTY COCHRAN, B.S.N., M.S.N., is Clinical Nurse Specialist—Acute Care for the Elderly, Department of Nursing; and LESLIE A. EIDEM, B.S., is Pharmacy Manager, Pediatric/Women’s Services and Medication Safety, Department of Pharmacy, WMC. ROBERT D. HANEKE, B.S., PHARM.D., is National Clinical Director, PharmaSource Healthcare, Inc., Sylvia, KS; at the time of this study he was Ambulatory and Geriatrics Clinical Specialist, Department of Pharmacy, WMC.

Address correspondence to Dr. Kramer at the Department of Pharmacy, Wesley Medical Center, 550 North Hillside, Wichita, KS 67214-4976 (joan.kramer{at}wesleymc.com).

Purpose. The feasibility of implementing an electronic system for targeted pharmacist- and nurse-conducted admission and discharge medication reconciliation and its effects on patient safety, cost, and satisfaction among providers and nurses were studied. Methods. This study was conducted in two phases: a preimplementation phase and a postimplementation phase. In the preimplementation phase, admission medication histories and discharge medication counseling followed standard care processes. During postimplementation, pharmacists and nurses collaborated to electronically complete admission and discharge medication reconciliation documentation. Four reports were developed for medication reconciliation documentation: (1) home medication profile report, (2) home medication reconciliation report, (3) discharge medication reconciliation report, and (4) patient discharge medication report. Patients were contacted after discharge to measure their satisfaction with the medication counseling and medication instructions received. Health care providers completed a survey indicating their satisfaction with the electronic medication reconciliation processes. Results. A total of 283 patients were included in the study. Patients in the postimplementation group took significantly more prescription and nonprescription medications, and their total number of medications significantly exceeded the number taken by the preimplementation group. Pharmacists completed significantly more dosage changes in the postimplementation phase than in the preimplementation phase. In the preimplementation phase, nurses identified more incomplete medication orders, dosage changes, and allergies than they did in the postimplementation phase. Patients in the postimplementation group reported a higher level of agreement on all survey items regarding adequate discharge medication instructions. Conclusion. Patients who had their medications electronically reconciled reported a greater understanding of the medications they were to take after discharge from the hospital, including medication administration instructions and potential adverse effects. Index terms: Computers; Documentation; Dosage; Errors, medication; Hospitals; Nurses; Patient information; Patient information; Pharmacists; Toxicity

 

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