International Journal of Clinical Pharmacy

, Volume 36, Issue 2, pp 430–437 | Cite as

Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge

  • T. Michael FarleyEmail author
  • Constance Shelsky
  • Shanique Powell
  • Karen B. Farris
  • Barry L. Carter
Research Article


Background Medication discrepancies may occur at transitions in care and negatively impact patient outcomes. Objective To determine if involving clinical pharmacists in hospital care, medication reconciliation and discharge medication plan communication can reduce medication discrepancies with a prospective, randomized, blinded, controlled trial. Setting A large, tertiary care, academic medical center. Method The intervention consisted of clinical pharmacist medication reconciliation, patient education and improved communication of the discharge medication plan, as devised by the hospital physician and care team, to primary care physicians and community pharmacists. Medication discrepancies were identified by blinded research pharmacists who reviewed primary care physician and pharmacy records at discharge through 90 days post-discharge to create 30- and 90-day medication lists. Main outcome measure Rate of medication discrepancies compared across groups. Results A total of 592 subjects from internal medicine, family medicine, cardiology and orthopedic services were evaluated for this study. Clinically important medication discrepancies in the primary care physician record were different between groups 30 days after hospital discharge following a clinical pharmacist’s intervention. The mean number of medication discrepancies per patient for the enhanced group being nearly half the number in the control group. However, this effect did not persist to 90 days post-discharge and did not extend to community pharmacy records. Conclusion The present study demonstrates the involvement of pharmacists in hospital care, medication reconciliation and discharge medication plan communication may affect the quality of the outpatient medical record.


Continuity of care Hospital discharge Medication discrepancies Medication reconciliation Medical record Pharmacist case manager Pharmacy record Transitions of care United States 



This study is supported, in part by the National Heart, Lung, and Blood Institute Grant 1RO1 HL082711.

Conflicts of interest

No conflicts of interest to report.


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Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014

Authors and Affiliations

  • T. Michael Farley
    • 1
    • 2
    Email author
  • Constance Shelsky
    • 1
  • Shanique Powell
    • 1
  • Karen B. Farris
    • 3
  • Barry L. Carter
    • 1
    • 4
  1. 1.Department of Pharmacy Practice and ScienceUniversity of Iowa College of PharmacyIowa CityUSA
  2. 2.Mercy Hospital Iowa CityIowa CityUSA
  3. 3.Social and Administrative Sciences (Pharmacy) Graduate ProgramUniversity of Michigan College of PharmacyAnn ArborUSA
  4. 4.Department of Family MedicineRoy J. and Lucille A. Carver College of MedicineIowa CityUSA

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