2025 Southeastern Residency Conference

Title: Clinical Impact of Pharmacist Involvement in Discharge Medication Reconciliation at a Rural Community Hospital 

Authors: Kyli Latimer, Abigayle Campbell

Background: Medication discrepancies occurring at hospital discharge have shown increased risk of adverse patient outcomes, hospital readmissions, and overall health care cost. Incorporation of a pharmacist within the discharge process can allow effective communication between transitions of care, prevent medication errors, and prevent patient harm. The objective of this study was to evaluate the impact of pharmacists on the discharge medication reconciliation process at a rural community hospital. 

Methods: This was a single center, retrospective chart review, pre-post pilot implementation study taken place at a rural community hospital. The pilot implementation period was conducted from February 24th, 2025 to March 26th, 2025, and consisted of having a clinical pharmacist decentralized to four different medical or telemetry floors (non-intensive care units). Pharmacist responsibilities primarily included discharge medication reconciliation and patient education, renal dose adjustments, anticoagulation monitoring and management, and transitioning therapies from intravenous to oral (IV to PO) routes. Retrospective data was collected over a one-week period for both the pre- (September 18th, 2023 to September 25th, 2023) and post- (March 17th, 2025 to March 24th, 2025) pilot groups. Adult patients discharged from one of four medical or telemetry floors were included in the study. Patients were excluded if they were discharged from any other patient care floor or outside of the designated hours of pharmacist coverage (weekdays from 0700 to 1530). Any patients that were discharged to a skilled nursing or rehabilitation facility were also excluded from receiving medication education at discharge. The primary outcome was the percentage of patients who had pharmacist involvement in the discharge process, defined as receiving both discharge medication reconciliation and medication education. Secondary outcomes assessed included the total number of medication errors identified during discharge medication reconciliation, the type and associated harm of each error, as well as patient discharge location. 

Results: A total of 170 patients were included in this study (93 patients in the pre-pilot group and 77 patients in the post-pilot group). Baseline characteristics were overall similar between groups. The percentage of patients that had both discharge medication reconciliation and medication education completed by a pharmacist increased by 16.6% (23.7% pre-pilot group vs. 40.3% post-pilot group). The number of medication errors identified at discharge was also higher in the post-pilot group compared to the pre-pilot group (22 (2.1%) vs. 7 (0.59%)). The most common type of medication error identified at discharge in both groups was ‘other’, often due to discrepancies with the frequency, directions, or patients’ preferred pharmacy at discharge.  

Conclusion: In this study, a higher percentage of patients had a pharmacist involved in the discharge process during the post-intervention group compared to those patients in the pre-pilot group, which also resulted in an increase in the percentage of medication errors identified in the post-pilot group. Limitations of this study include it being a retrospective chart review with minimal sample size, reliance on pharmacy specific documentation, and the limited study period of review. Despite this, these results show the benefit of pharmacist involvement in the discharge process. Future directions include the optimization and standardization of the current discharge process as well as the implementation of a pharmacist-led discharge process. 

Contact: kyli.latimer@selfregional.org