Hospitals must balance costs associated with pharmacist medication reconciliation (e.g., salary) with prevented harm and cost avoidance (e.g., unreimbursed expenses resulting from medication error). This study found an estimate cost avoidance of $47,000 - $231,000 during one month in one hospital. The highest-risk, highest-cost classes were insulin, antithrombotics, and opioids. In resource-limited environments, focusing on the highest-cost classes could avoid significant cost and patient harm.

An increasing strategy to reduce adverse drug events (ADE) is pharmacist medication review, typically involving other members of the care team. This qualitative review summarizes randomized studies of interventions with multidisciplinary care teams to reduce ADE. Most interventions were time-intensive (1- to 2-hours), including four steps (data collection, appraisal report, multidisciplinary medication review, follow up). Most teams consisted of a pharmacist, physician, and nurse, although some included other providers such as psychologists or social workers.

Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect or incomplete medication distribution to patients. This study describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge at community pharmacies. An increasing percentage of TCAM referrals were completed post-intervention, but 45% were not completed at all or took longer than one month. The impact of the TCAM service on adverse drug events (ADE) and unintentional medication discrepancies (UMD) was uncertain. Future research may explore reasons for low/late completions or focus on high-risk medications, as those were associated with the most ADE and UMD.

Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

Obtaining a best possible medication history (BPM) is an important component of successful medication reconciliation programs. This study compared the impact of a pharmacy-led medication reconciliation program including BPMH on adverse drug events (ADEs) and complications among high-risk, complex patients across 16 hospitals. In the six months following implementation, 80,000 reconciliations were completed and nearly 40% required additional medication follow-up and/or clarification. Researchers identified a statistically significant decrease in both ADEs and complications after implementation.

Older adults taking 5 or more medications daily (i.e., polypharmacy) face numerous challenges to taking them safely. In this study, patients, caregivers, and clinicians describe methods to taking medications safely, difficulties they face, and ways prescribers and pharmacists can assist patients. Medication reviews, a common strategy to ensure safe polypharmacy, were requested by patients to clear up confusion around generics, timing, limitations, and side effects.

Medication safety in ambulatory care settings is an area of growing concern. This article describes ACTMed (ACTivating primary care for MEDicine safety), a cluster randomized trial set in Australia which intends to improve medication safety in primary care settings. The ACTMed intervention will use health information technology (e.g., clinical indicator algorithms), guideline-based clinical recommendations, shared decision-making, and financial incentives to reduce serious medication-related harm, medication-related hospitalizations, and death.

Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.

Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.

Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.

Older adults with cancer are typically prescribed multiple medications (i.e., polypharmacy) and are therefore at risk of adverse drug events (ADE). In this study, the medical records of older adults (those at least 70 years old) receiving cancer care who had an unplanned hospital admission were reviewed to determine if it was potentially related to an ADE. Of the hospitalized patients, more than half were potentially due to ADE at three and six months after the initial oncology visit. Including a clinical pharmacist may help reduce ADEs and hospitalizations.

Medication reconciliation is used when a patient moves from one level or location of care to another, to ensure they are receiving the appropriate medications. This retrospective study reviewed completed medication reconciliations of adult patients transferring from the intensive care unit to the ward. Nearly one in five had an error requiring physician changes to the order. Of those errors, 19% were high-alert medications, most notably low-molecular-weight heparin.

Designated emergency department (ED) pharmacists are increasingly used to improve the quality of medication administration in the ED. This qualitative study explored patient perceptions of medication safety before and during an ED pharmacist-led intervention (including medication reconciliation and medication review) in collaboration with ED physicians. Participants underscored the importance of trust and responsibility but noted that it was not important who carried out these medication-related tasks, but rather that the participant received the help they needed.

Direct oral anticoagulant (DOAC) dosing is complex and can lead to medication errors. This analysis of 15,730 incident reports involving DOACs reported in the United Kingdom between 2017 and 2019 found that the majority (87.6%) were due to active failures and 2.2% resulted in moderate/severe harm or death. This PSNet WebM&M commentary discusses approaches to improving safety when prescribing DOACs.

Pharmacists play a critical role in medication safety. This article evaluated the impact of a pharmacist-led information technology intervention (PINCER) among a retrospective cohort of 56.8 million National Health Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.

Potentially inappropriate medications (PIM) and polypharmacy, defined as taking 5 or more medications, can increase the risk of hospitalization and other adverse events for older adults. This article describes the implementation and success of a patient-centered medication review conducted at the time of hospital discharge. Nearly all patients followed up with their general practitioner on the pharmacist’s recommendations and approximately three-quarters were implemented. Including the patient and/or caregiver was a key component of the intervention. 

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.