SHM Converge Scientific Abstract ePoster Gallery-Pharmacist Discharge Medication Review Prevents Errors and Potential Patient Harm

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This pilot quality improvement study evaluated pharmacist-led discharge medication reconciliation (PMRD) on an adult internal medicine service at an academic medical center over four weeks. The goal was to determine how many discharge medication errors pharmacists could identify, what level of patient harm they could prevent, and the potential financial impact of preventing those errors.<br /><br />Pharmacists reviewed discharge medication lists prepared by senior residents, documented any errors, and classified each error’s type and severity using an adapted NCC MERP scale. Physicians then judged whether each error could have led to readmission. Readmission data were used to estimate possible cost avoidance.<br /><br />A total of 40 medication errors were identified in 31 patients. The most common problems were duplicate medications, incorrect duration of therapy (especially antibiotics), and barriers to medication access such as refill needs, coverage issues, or pharmacy changes. Together, these accounted for 70% of all errors. More than half of the errors (58%) could have caused serious harm, including one life-threatening error. Errors of all types had the potential to cause harm, showing that no single category was low-risk.<br /><br />Using institutional cost estimates and extrapolating from one team to all internal medicine teams, the study estimated annual cost avoidance of about $1.61 million. A sensitivity analysis also suggested meaningful savings even with conservative assumptions.<br /><br />The study was limited by its small sample size, short duration, and lack of a direct comparison group. Despite these limitations, the findings support pharmacist-led discharge medication reconciliation as an effective strategy to prevent serious medication-related harm and reduce costs. The program was expanded to additional services, and future work should focus on identifying high-risk patients when pharmacist staffing is limited.

Asset Subtitle

Tiffany Pon

Meta Tag

Author List Kathie Le, Linda Zheng, Rebecca Hluhanich, Sarah Bajorek, Tiffany Pon

Category Research

Concept Pharmacist-Led Discharge Medication Reconciliation

Concept Discharge Medication Error

Concept Medication Reconciliation

Concept Medication Error Severity

Concept Life-Threatening Harm

Distinguished Non-Finalist

Presenter Organization University of California, San Francisco

Presenting Author Tiffany Pon

Track Transitions of Care

Keywords

pharmacist-led discharge medication reconciliation

medication errors

adult internal medicine

patient harm prevention

duplicate medications

antibiotic duration

medication access barriers

readmission risk

cost avoidance

quality improvement study

Pharmacist-Led Discharge Medication Reconciliation

Discharge Medication Error

Medication Reconciliation

Medication Error Severity

Life-Threatening Harm