International Journal of Clinical Pharmacy

, Volume 37, Issue 2, pp 310–319 | Cite as

Interdisciplinary collaboration in the provision of a pharmacist-led discharge medication reconciliation service at an Irish teaching hospital

  • Deirdre M. HollandEmail author
Research Article


Background Medication reconciliation is a basic principle of good medicines management. With the establishment of the National Acute Medicines Programme in Ireland, medication reconciliation has been mandated for all patients at all transitions of care. The clinical pharmacist is widely credited as the healthcare professional that plays the most critical role in the provision of medication reconciliation services. Objectives To determine the feasibility of the clinical pharmacist working with the hospital doctor, in a collaborative fashion, to improve the completeness and accuracy of discharge prescriptions through the provision of a pharmacist led discharge medication reconciliation service. Setting 243-bed acute teaching hospital of Trinity College Dublin, Ireland. Method Cross-sectional observational study of discharge prescriptions identified using non-probability consecutive sampling. Discharge medication reconciliation was provided by the clinical pharmacist. Non-reconciliations were communicated verbally to the doctor, and documented in the patient’s medical notes as appropriate. The pharmacist and/or doctor resolved the discrepancies according to predetermined guidelines. Main outcome measures Number and type of discharge medication non-reconciliations, and acceptance of interventions made by the clinical pharmacist in their resolution. Number of discharge medication non-reconciliations requiring specific input of the hospital doctor. Results In total, the discharge prescriptions of 224 patients, involving 2,245 medications were included in the study. Prescription non-reconciliation was identified for 62.5 % (n = 140) of prescriptions and 15.8 % (n = 355) of medications, while communication non-reconciliation was identified for 92 % (n = 206) of prescriptions and 45.8 % (n = 1,029) of medications. Omission of preadmission medications (76.6 %, n = 272) and new medication non-reconciliations (58.5 %, n = 602) were the most common type. Prescription non-reconciliations were fully resolved on 55.7 % (n = 78) of prescriptions prior to discharge; 67.9 % (n = 53) by the doctor, 26.9 % (n = 21) by the clinical pharmacist, and 5.2 % (n = 4) by the joint input of doctor and pharmacist. All communication non-reconciliations were resolved prior to discharge; 97.1 % (n = 200) by the pharmacist, and 2.9 % (n = 6) by both doctor and pharmacist. Conclusion This study demonstrates how interdisciplinary collaboration, between the clinical pharmacist and hospital doctor, can improve the completeness and accuracy of discharge prescriptions through the provision of a pharmacist led discharge medication reconciliation service at an Irish teaching hospital.


Clinical pharmacy Discharge prescription Hospital pharmacy In-patient Interdisciplinary Ireland Medication reconciliation Patient safety 



The author acknowledges the contribution of Dr. Anita Weidmann, Robert Gordon University, Scotland, in bringing this research to completion. Also all staff at Naas General Hospital who facilitated the study. Additionally, Ms. Mairéad Galvin who guided data collection and analysis.


The author has not received any financial support for this work.

Conflicts of interest

The author declares no conflicts of interest.


  1. 1.
    Madden D. Building a culture of patient safety. Report of the commission on patient safety and quality assurance. Department of Health, Ireland; 2008.Google Scholar
  2. 2.
    Royal College of NCHDs of Ireland/Irish Association of Directors of Nursing and Midwifery/Therapy Professions Committee/Quality and Clinical Care Directorate, Health Service Executive. Report of the National Acute Medicine Programme 2010 (internet).
  3. 3.
    National Prescribing Centre. medicines reconciliation: a guide to implementation. Good practice guide, 5 min guides; 2008.Google Scholar
  4. 4.
    Institute for Healthcare Improvement. How-to guide: prevent adverse drug events by implementing medication reconciliation (internet).
  5. 5.
    Rozich DJ, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Patient safety standardisation as a mechanism to improve safety in healthcare. Jt Comm J Qual Saf. 2004;30(1):5–14.PubMedGoogle Scholar
  6. 6.
    Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalised patients. Am J Health Syst Pharm. 2004;61(16):1689–95.PubMedGoogle Scholar
  7. 7.
    Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15:122–6.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Scullin C, Scott MG, Hogg A, McElnay J. An innovative approach to integrated medicines management. J Eval Clin Pract. 2007;13(5):781–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Medication reconciliation at an academic medical centre: implementation of a comprehensive program from admission to discharge. Am J Health Syst Pharm. 2009;1(66):2126–31.CrossRefGoogle Scholar
  10. 10.
    Greenwald JL, Halasyamani L, Greene J, LaCivita C, Stucky E, Benjamin B, et al. Making inpatient medication reconciliation patient centred, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5:477–85.CrossRefPubMedGoogle Scholar
  11. 11.
    National Institute for Health and Clinical Excellence/National Patient Safety Agency. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. PSG001; 2007.Google Scholar
  12. 12.
    Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2007(2):314–23.CrossRefGoogle Scholar
  13. 13.
    Grimes TC, Duggan CA, Delaney TP, Graham IM, Conlon KC, Deasy E, et al. Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation. Br J Clin Pharmacol. 2011;71(3):449–57.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Wong JD, Bajcar JM, Wong GG, Alibhai SMH, Huh JH, Cesta A, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373–9.PubMedGoogle Scholar
  15. 15.
    Bolas H, Brookes K, Scott M, McElnay J. Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland. Pharm World Sci. 2004;26(2):114–20.CrossRefPubMedGoogle Scholar
  16. 16.
    Zemke R, Kramlinger T. Figuring things out: A trainer’s guide to needs and task analysis. Reading: Addison-Wesley Publishing; 1986.Google Scholar
  17. 17.
    Bowling A. Research methods in health: investigating health and health services. 3rd ed. Berkshire: Open University Press; 2009.Google Scholar
  18. 18.
    Fitzsimons M, Grimes T, Galvin M. Sources of preadmission medication information: observational study of accuracy and availability. Int J Pharm Pract. 2011;19(6):408–16.CrossRefPubMedGoogle Scholar
  19. 19.
    British Medical Journal/Royal Pharmaceutical Society of Great Britain. British national formulary 62. London: BMJ Group & RPS Publishing; 2011.Google Scholar
  20. 20.
    McMillen TE, Allan W, Black PN. Accuracy of information on medicines in hospital discharge summaries. Intern Med J. 2006;36:221–5.CrossRefGoogle Scholar
  21. 21.
    Wilcock M, Lawrence J. Medication at discharge: is enough information provided? Med Manag. 2008;5:19–22.Google Scholar
  22. 22.
    Glintborg B, Anderson SE, Dalhoff K. Insufficient communication about medication use at the interface between hospital and primary care. Qual Saf Health Care. 2006;16:34–9.CrossRefGoogle Scholar
  23. 23.
    Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Can Med Assoc J. 2005;173(5):510–5.CrossRefGoogle Scholar
  24. 24.
    Grimes TC, Duggan CA, Delaney TP. Pharmacy services at admission and discharge in adult, acute public hospitals in Ireland. Int J Pharm Pract. 2010;18(6):346–52.CrossRefPubMedGoogle Scholar
  25. 25.
    Tully MP, Cantrill J. What hospital doctors think GPs need in a discharge summary? Conference of the European society of general practice/family medicine. Wonca Region Europe, Finland; 2001.Google Scholar
  26. 26.
    Witherington EMA, Pirzada OM, Avery AJ. Communicating gaps and readmission to hospital for patients aged 75 years and older: observational study. Qual Saf Health Care. 2008;17:71–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646–51.CrossRefPubMedCentralPubMedGoogle Scholar
  28. 28.
  29. 29.
    Dean B, Schachter M, Vincent C, Barber B. Causes of prescribing errors in hospital in-patients: a prospective study. Lancet. 2002;359(9315):1373–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Barnsteiner JH. Medication Reconciliation. In: Hughes RG, editor. Patient safety and quality: an evidence based handbook for nurses. Rockville: Agency for Healthcare Research and Quality; 2008.Google Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Authors and Affiliations

  1. 1.Health Service Executive, Dublin Mid-LeinsterNaas General HospitalNaasRepublic of Ireland

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