2025 Southeastern Residency Conference

Title: Impact of Pharmacist Discharge Review of Oral Anticoagulation Medications in Hospitalized Patients 


Authors: Courtney Self, PharmD; Jill McHugh, RPh, BCPS; Colin Busbee, PharmD; Rebecca Epperson, PharmD, BCPS 


Objective: To assess the impact of pharmacist discharge medication review on the rate of medication errors in hospitalized patients being discharged on oral anticoagulant therapy.


Self Assessment Question: How do pharmacists' review of discharge medication reconciliations impact transitions of care in current practice?


Background: Anticoagulation therapy is considered a high-risk medication with an increased concern for causing patient harm due to clotting or bleeding if improperly prescribed. Anecdotally, there has been an increase in the number of errors found with patients’ oral anticoagulant therapy on medication reconciliations at the study site. Per protocol, anticoagulants are reviewed daily during admission, but there is no standard review of discharge medication reconciliations. The purpose of this study is to assess the impact of pharmacist discharge medication review on the rate of medication errors in hospitalized patients being discharged on oral anticoagulant therapy.


Methods: This prospective, single-arm study was conducted over a three-month period to evaluate the benefit of clinical pharmacist review of the discharge medication reconciliation at a community hospital.  Patients were included if they were at least 18 years of age, were discharged from either 4 North or Progressive Care units Monday-Friday from 0700-1530 between December 1, 2024-February 28, 2025, and had an oral anticoagulant on their medication reconciliation. If a patient met the inclusion criteria, the pharmacist reviewed the discharge medication reconciliation for errors found and suggested any interventions to the prescriber. The primary endpoint is to identify the total number of oral anticoagulant medication errors found in the discharge medication reconciliation and the number corrected by pharmacist intervention. Secondary endpoints include identifying the total number of other medication errors found in the discharge medication reconciliation and the number corrected by pharmacist intervention, categorizing the types of errors corrected, evaluating the rate of prescriber acceptance of interventions, and estimating the time spent on each discharge reconciliation. 


Results: A total of 52 patients’ discharge medication reconciliations were included in the study and reviewed. For anticoagulation therapy, 7 errors (13.5%) were found, and suggestions to fix the errors were made to the provider for all seven medication errors. Four (57.1%) medication suggestions were accepted before patient discharge. For other medications, 9 errors (1.1%) were found, and suggestions to fix the errors were made for 8 of the errors found. Two (25%) medication suggestions were accepted for the other medication group before discharge. Most errors were categorized as incomplete/inaccurate patient instructions, with 31.3% of errors falling into this category. The average time spent reviewing discharge medication reconciliations was 14 minutes.


Conclusion: Pharmacist review of discharge medication reconciliation led to reduced numbers of medication errors in both anticoagulation therapy and other therapies.