2025 Southeastern Residency Conference

The Impact of Pharmacist-Led Medication Reconciliation in High-Risk Patient 
Populations 
Qynn Celichowski 
Parkridge Medical Center 


Objective: List potential errors that may occur if a proper medication reconciliation is not performed. 


Self-Assessment Question: When should a medication reconciliation be completed? 


Background: Pharmacist-led medication reconciliation can help reduce medication errors, adverse effects, readmissions, and more by providing updated medication lists, resolving discrepancies, and preventing duplicate and wrong therapy. Medication Reconciliation is the process of obtaining current and accurate medication information for a patient upon admission, transfer, and discharge. This process is crucial in providing accurate home medication lists for inpatient use and discharge instructions. The purpose of this study was to evaluate the effects of pharmacy involvement in the medication reconciliation process in high-risk patient populations.   


Methods: A single-center prospective review of the effects of pharmacy-led medication reconciliation was performed. Medication reconciliations were completed by a pharmacy resident in high-risk patient populations identified by a clinical pharmacy workflow tool. These populations are defined as those with chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, acute myocardial infarction (AMI), coronary artery bypass graft surgery (CABG), and elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA). The pharmacy resident documented time spent on medication reconciliation, total number of medications, omissions, duplications, wrong drugs, and inaccurate dosages. 


Results: There were 54 medication reconciliations completed by the pharmacy resident. 42.6% of patients were 30-day re-admissions. On average, it took 20 minutes to complete a medication reconciliation. The average number of medications was 13, the average number of medications omitted was 2, and the average number of wrong dosages and medications was 3.   


Conclusion: The current data suggests the need for pharmacy involvement in the medication reconciliation process. Numerous discrepancies have been identified and addressed through the implementation of pharmacy-led medication reconciliation process.