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Abstract
Objective There were three main objectives of the study: to determine the overall compliance of medication reconciliation over 4 years in a tertiary care hospital, to compare the medication reconciliation compliance between paper entry (initial assessment forms) and computerised physician order entry (CPOE), and to identify the discrepancies between the medication history taken by the physician at the time of admission and those collected by the pharmacist within 24 hours of admission.
Methods This study was conducted at a tertiary care hospital in a lower middle-income country. Data were gathered from two different sources. The first source involved retrospective data obtained from the Quality and Patient Safety Department (QPSD) of the hospital, consisting of records from 8776 patients between 2018 and 2021. The second data source was also retrospective from a quality project initiated by pharmacists at the hospital. Pharmacists collected data from 1105 patients between 2020 and 2021, specifically focusing on medication history and identifying any discrepancies compared with the history documented by physicians. The collected data were then analysed using SPSS V.26.
Results The QPSD noted an improvement in physician-led medication reconciliation, with a rise from 32.7% in 2018 to 69.4% in 2021 in CPOE. However, pharmacist-led medication reconciliation identified a 25.4% (n=281/1105) overall discrepancy in the medication history of patients admitted from 2020 to 2021, mainly due to incomplete medication records in the initial assessment forms and CPOE. Physicians missed critical drugs in 4.9% of records; pharmacists identified and updated them.
Conclusion In a lower middle-income nation where hiring pharmacists to conduct medication reconciliation would be an additional cost burden for hospitals, encouraging physicians to record medication history more precisely would be a more workable method. However, in situations where cost is not an issue, it is recommended to adopt evidence-based practices, such as integrating clinical pharmacists to lead medication reconciliation, which is the gold standard worldwide.
- Medication reconciliation
- Evidence-Based Practice
- Healthcare quality improvement
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Before this study, it was known that medication reconciliation is crucial for patient safety, as it reduces the risk of medication errors and discrepancies. However, in some healthcare settings, especially in resource-limited environments like lower middle-income countries, achieving high physician compliance with medication reconciliation has been a challenge. Limited awareness of its importance, lack of evidence-based measures and difficulty in understanding the reconciliation process were some of the known factors contributing to suboptimal compliance.
WHAT THIS STUDY ADDS
This study adds valuable insights into the medication reconciliation compliance trends over 4 years in a Pakistani tertiary care hospital. It demonstrates a positive trend of improvement in physician compliance with medication reconciliation, both in initial assessment forms and the computerised physician order entry system. Moreover, the study highlights significant discrepancies between the medication histories recorded by physicians and those collected by pharmacists, emphasising the importance of pharmacist-led medication reconciliation in identifying and resolving errors.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The study offers perceptions on practical methods to raise medication reconciliation compliance. It emphasises how crucial pharmacist-led reconciliation is for minimising differences. To improve patient safety, policymakers may choose to incorporate pharmacist-led reconciliation procedures.
Introduction
To improve the quality of patient care is the primary goal of healthcare providers worldwide. Medication reconciliation improves patient safety and reduces the risk of medication errors. The Joint Commission has defined medication reconciliation as ‘the process of comparing a patient’s medication orders to all of the medications that the patient has been taking’.1
By accurately and completely reconciling home medications, patient safety can be improved, and the risk of medication errors and discrepancies can be reduced.2 Comprehensive medication history recording is essential in medical files, enabling comparison and adjustment of patients’ medication for optimal treatment throughout their hospital stay.3 4 It is an important process of safe medication management as it can affect a patient’s outcome during hospitalisation.
Some tertiary care and private hospitals in Pakistan have taken certain steps to improve medication reconciliation to steer clear of medication errors and reduce discrepancies. These steps include implementing medication reconciliation in computerised physician order entry (CPOE) and electronic-based prescriptions as well as developing policies, procedures and quality improvement teams.5 However, limited resources and funding remain a hindrance to addressing medication-related patient safety issues in Pakistan. Also, there has been a persistent challenge for physicians, with poor compliance over the years, despite various strategies being adopted to reinforce it. Lack of awareness regarding its importance, absence of evidence-based structured measures and difficulty in comprehending the process of medication reconciliation are some of the reasons behind the suboptimal performance. According to a study done in Australia, more than 60% of nurses think that time constraints and staffing shortages are obstacles to optimal medication reconciliation.6
Another way that can be adopted to improve medication reconciliation is to implement the gold standard method that involves a pharmacist interviewing patients about their preadmission medication regimen and correcting that in the patient history, this plays a crucial role in reducing the risk of medication errors and discrepancies during admission, transfer and discharge. Despite the evolution of pharmacy services beyond inventory-based and industry-oriented services, they have not yet been fully integrated into patient-focused care systems. Pharmacist-led medication reconciliation is a blessing or an additional burden in a lower middle-income country like Pakistan, and needs to be explored.
In this study, we compared the overall compliance to medication reconciliation in different departments of a tertiary care hospital in Pakistan over 4 years. Additionally, we aimed to determine whether pharmacist-led medication reconciliation is an effective way to achieve good compliance with medication reconciliation at admission. Another objective was to identify the discrepancies between the medication history taken and entered by the physician at the time of admission and those collected by the pharmacist within 24 hours of admission. The study’s results can provide valuable insights into the necessity of establishing a system that ensures good compliance with medication reconciliation, to prevent drug-related problems and shed light on whether there is a need to revise the audit method for checking compliance to medication reconciliation.
Materials and methods
Study design/data source
To evaluate the medication reconciliation process, this study was carried out at a tertiary care hospital in Pakistan, a well-known large tertiary care hospital with 740 beds that serves a varied population of patients from various sociocultural and ethnic backgrounds. On admission to inpatient services, whether from the emergency department or outpatient clinics, patients are assessed by a primary care physician. The physician conducts a comprehensive evaluation, gathering detailed information about the patient’s medical history, current complaints and prescribed medications taken at home. This medication history is then documented by the primary care physician in both the patient’s physical files and the electronic system known as CPOE. This is done at the time of admission for all the patients. The Quality and Patient Safety Department (QPSD) of the hospital performs audits to review both patient files and electronic records, checking for the documentation of medication history, including the name, frequency and dosing information.
The study was conducted from 1 June 2022 until 1 January 2023. This is a retrospective study which used two sources of data. The first source involved retrospective data obtained from the QPSD, encompassing information from 8776 patients between 1 January 2018 and 31 December 2021. This included records of both the initial assessment forms and CPOE audited by the QPSD. The second data source originated from a quality project initiated by the pharmacy. As part of this project, data were collected from 1105 patients between 1 January 2020 and 31 December 2021, focusing on recording medication history and identifying any discrepancies from the history collected by the physicians. In this study, a convenient sampling technique was used.
Eligibility criteria
Our study encompassed all departments within the hospital that provide inpatient services. These included: heart, lung and vascular department; musculoskeletal and sports medicine; children’s hospital; women’s healthcare; kidney and bladder; mind and brain; cancer care; internal medicine; eye and ear, nose and throat (ENT); and gastrointestinal and surgery. However, we excluded patients who were admitted to day care, visiting the outpatient department, as well as those seeking care from the family medicine, emergency, and teeth and skin departments as they keep patients for less than 24 hours and have no admitting facility. However, the quality project by the pharmacists also included data from the emergency department.
Interventions to improve medication reconciliation
In present times, most of the hospital set-ups in Pakistan rely on paper-based recording of patient medical history, including medication history, which is typically stored in the patient file. Subsequently, this medication history is entered into the CPOE system. While the CPOE system is increasingly adopted by healthcare institutions in Pakistan, it tends to be more time consuming compared with the traditional manual order-writing process, leading to duplicated efforts. Furthermore, inadequate training of staff can lead to non-compliance, which may be a potential cause for the disparity observed between medication reconciliation in the initial assessment forms and the CPOE system. Over the years, our hospital has taken a proactive approach in switching towards electronic health records (EHR), which will eliminate paper and reduce the duplication of work. Until that time, the hospital has taken many initiatives to improve medication reconciliation compliance with the current resources.
One of the significant interventions was the formation of a ‘Quality Improvement Team’ comprising both doctors and nurses, which devised strategies to reinforce medication reconciliation. The other interventions done to enhance medication reconciliation at our hospital are summarised in figure 1.
Interventions done to enhance medication reconciliation process.
Pharmacist-led medication reconciliation
The pharmacy department at the hospital initiated a quality project in 2020 to measure the quality of medication reconciliation among inpatients. The gold standard process of pharmacy-led medication reconciliation was implemented among a sample of inpatients, with a team of pharmacists collecting the best possible medication histories through in-person interviews within 24 hours of admission. The pharmacists used a convenient sampling technique for data collection. These medication histories were then compared with those obtained by physicians in the initial assessment forms and CPOE for discrepancies.
Discrepancies were defined as any variations between the medication history taken by the physician at the time of admission and that collected by the pharmacist within 24 hours of admission (table 1). Unfortunately, due to resource limitations, the project was unable to proceed and was consequently terminated in 2021.
Labelling done by the pharmacist for the discrepancies
Patient and public involvement
Patients’ confidentiality and anonymity were maintained, no identifiers that could be used to track participants were used and the data were identified by a serial number.
Data analysis
Data were analysed using Statistical Package for the Social Sciences (SPSS) for Windows V.26. Tables and charts were created on SPSS V.26 and Microsoft Excel V.2010. Descriptive statistics were reported as frequency (percentage) for categorical variables.
Results
Compliance to medication reconciliation by physicians at admission over a period of 4 years
For this study, a thorough review of 8776 records from 2018 to 2021 obtained from the QPSD was done. As per the review, the initial assessment forms at admission showed an overall physician compliance of around 93.9% in 2018. While compliance slightly declined to 92.9% in 2019, it increased to 94.4% in 2020 and 95.2% in 2021, indicating a positive trend in medication reconciliation. However, it was observed that compared with the initial assessment form there was lower compliance with medication reconciliation in the CPOE system, but a significant increase was observed over the 4-year period in the transcription of medication history into the CPOE, with 32.7% compliance in 2018, 36.4% in 2019, 67.9% in 2020 and 69.4% in 2021.
Of the total 8776 records reviewed, a high compliance rate of 93.6% (n=8213) was observed for medication reconciliation over the 4 years, with complete medication history being recorded by physicians in initial assessment forms on admission. However, only 31.9% (n=2805) of the patients had their complete medication history transcribed into the CPOE. A significant number (26.6%, n=2336) of the CPOE records did not have any medication history (table 2).
Compliance with recording complete medication history in initial assessment forms and CPOE in different departments over 4 years
As compared with other departments, over the 4 years, eye and ENT showed the highest compliance of 97.7% with medication reconciliation in the initial assessment form, though in the CPOE, the heart, lung and vascular department had the highest compliance of around 45% (figure 2).
Medication reconciliation compliance across different departments(from 1 January 2018 to 31 December 2021).
Figures 3 and 4 depict a comparison of medication reconciliation performed (>90%) by individual departments on both the initial assessment forms and CPOE, respectively. From 2018 to 2021, most of the departments showed an improvement in the outcome measure (percentages of records with more than 90% medication reconciliation) at both the initial assessment and in CPOE, and that the variability (range of percentage completion) between departments decreased.
Comparison of medication reconciliation done (>90%) by each department in the initial assessment forms
Comparison of complete medication reconciliation done (>90%) by each department in CPOE
Discrepancies in medication history identified by pharmacy-led medication reconciliation process
During the period from 2020 to 2021, the pharmacy team investigated the medication reconciliation process for 1105 patients who were admitted to various departments. The investigation revealed discrepancies in 25.4% (n=281/1105) between the medication history recorded by the pharmacist and the information documented by physicians in the initial assessment forms and CPOE system. Please refer to table 3 for more details.
Discrepancies observed by pharmacist-led medication reconciliation in initial assessment forms and CPOE at patient admission (n=1105)
In around 4.9% (n=55) of the cases, physicians missed high alert/critical drugs like insulin dosage and frequency, prophylactic antibiotics and cardiac medications (such as furosemide, captopril and spironolactone) in both the initial assessment form and CPOE. These drugs were identified by pharmacists during medication reconciliation and updated in the system. The musculoskeletal and sports medicine department had the lowest discrepancy at just 5.4% (see table 4).
Discrepancies found through pharmacist-led medication reconciliation between initial assessment forms and CPOE in different departments from 2020 to 2021
Discussion
Medication reconciliation at the time of admission, which lays the groundwork for reconciliation during the hospital stay, is essential for patient safety. To increase its accuracy, nevertheless, there needs to be standardisation among diverse healthcare fields. As a multidisciplinary activity, it entails shared accountability between the clinicians caring for the patient, including the doctors, nurses, pharmacists and other clinicians. This study sheds light on the medication reconciliation pattern observed over 4 years in a tertiary care hospital located in a lower middle-income country. The research also identifies discrepancies in medication reconciliation between physicians and pharmacists.
In our study, we found that physicians complied well with medication reconciliation in the initial assessment file during admission. However, we observed a significant improvement in the transcription of medication history into the CPOE system over the years, with compliance rates increasing from 32.7% in 2018 to 69.4% in 2021. This improvement in compliance can be attributed to various interventions implemented at our hospital, as described above. Overall, these interventions had a positive impact on compliance with medication reconciliation and can serve as a model for other institutions to improve patient safety and outcomes.
Different measures have been adopted over the years which have shown to improve compliance to medication reconciliation. The positive recognition programme was one such example where there was recognition and appreciation for medication reconciliation compliance greater than 90% for the team of rotating doctors at John Hopkins University School of Medicine which led to a fourfold increase in compliance in an outpatient setting.7 Another study showed that hands-on interactive training sessions, close monitoring, reinforcement by assigned physicians and audit reports in a hospital in Saudi Arabia improved admission medication reconciliation remarkably in 2015.4 A hospital in Abu Dhabi improved its medication reconciliation compliance from 40% to 85% in 2014–2015 over 15 months by sharing daily audit reports of admission medication reconciliation, awareness and education regarding filling of online reconciliation forms, mandatory electronic hands-on training for the newly hired physicians for filling the forms and screening of all admissions for medication reconciliation the following morning.8
Studies indicate that medication reconciliation performed by a clinical pharmacist can significantly reduce medication discrepancies.9 10 This is because their training and expertise make them better qualified to perform the reconciliation process.11 Pharmacist-led medication reconciliation is considered the gold standard for ensuring accuracy in the medication history of patients. However, it may not always be a feasible option, particularly in lower middle-income countries where resources are limited. In our hospital, we initiated pharmacist-led medication reconciliation as a quality project. Unfortunately, due to insufficient resources, we had to discontinue the programme after just 2 years. In 1105 patients, during medication reconciliation, our investigation discovered a medication discrepancy of 25.4%, which was discovered by pharmacists in the records from 2020 to 2021. Additionally, high alert/critical medications were absent from approximately 5% of the discrepant records, which was similarly observed in some previous research.11 12 A recent study examining medication errors during history taking at admission in 304 general medicine inpatients found a 67% medication discrepancy.13
Our study has important implications for healthcare providers and policymakers, providing valuable insights into the journey of medication reconciliation compliance over 4 years in a tertiary care hospital. The findings demonstrate that medication reconciliation compliance rates can be improved over time with the implementation of effective strategies and interventions. It is crucial to regularly monitor and evaluate compliance rates to identify areas for improvement and ensure sustained improvements in patient safety and quality of care. Our study can serve as a guide for healthcare providers and policymakers in developing effective strategies to improve medication reconciliation compliance rates and ultimately enhance patient safety and quality of care.
Future research in this area can further explore the effectiveness of different interventions to improve medication reconciliation compliance and evaluate their long-term impact on patient outcomes. Encouraging and supporting physicians to take responsibility for medication reconciliation can be a feasible and effective approach, especially in lower middle-income countries where resources for pharmacist-led medication reconciliation may be limited. Overall, our study highlights the importance of ongoing efforts to improve medication reconciliation compliance rates, which can have a significant impact on patient safety and the quality of care provided to patients.
To the best of our knowledge, this research in Pakistan represents the first study of its kind focusing on medication reconciliation compliance surveys conducted over 4 years. The study sheds light on the gold standard practice of pharmacist-led medication reconciliation and uncovers significant discrepancies between the reconciliation performed by physicians and pharmacists. By examining compliance over an extended timeframe, the study provides valuable insights into the long-term effectiveness and sustainability of medication reconciliation practices in Pakistan.
The findings of this study underscore the need for greater collaboration and coordination between physicians and pharmacists in the reconciliation process. It emphasises that pharmacist-led reconciliation, which follows established guidelines and best practices, holds immense potential to address the existing discrepancies and improve patient care. By bringing attention to the disparities between physician and pharmacist-led medication reconciliation, this research catalyses implementing standardised protocols and quality assurance measures. It encourages healthcare institutions and policymakers to prioritise the integration of pharmacist-led reconciliation practices into routine clinical workflows, ultimately ensuring safer medication management for patients across Pakistan.
Based on our study and literature review, we have certain recommendations which might result in improvement in the medication reconciliation process. Given the critical importance of accurate medication reconciliation in ensuring patient safety, it is worth considering reforms to payment structures that incentivise and support physician involvement in the process. However, we also propose an alternative approach (considering the poor resources in middle-income countries), instead of monetary incentives, recognition through awards or certificates may be more effective. This recognition can also be integrated into their performance evaluations. Additionally, we advocate for the inclusion of trainees in quality improvement projects to foster a collaborative and educational environment. We also advocate for the transition to a paperless system. Instead of duplicating work by initially recording medication information in a physical file and subsequently inputting it into the CPOE system, we propose bypassing the physical file altogether and entering the data directly into the EHR, seamlessly integrating it with the CPOE system. In countries where the resource is not a constraint, we advise implementing pharmacy-led medication reconciliation in the same manner as done by our pharmacy. That is, pharmacists collect the best possible medication histories through in-person interviews within 24 hours of admission and collaborate with the doctors’ team in case of discrepancy. As per our findings, the pharmacist-led reconciliation, which follows established guidelines and best practices, holds immense potential to address the existing discrepancies and improve patient care.
Limitations
As the resources were limited, our study was conducted at a single tertiary care hospital; nevertheless, it involved different departments to facilitate the comparison of compliance to admission reconciliation among physicians of various disciplines. However, we acknowledge that our assessment of medication reconciliation was limited to the time of admission only and did not include transfers across different departments or discharge of patients, which is a potential limitation of this study. Another limitation stemming from the retrospective nature of the data was the inability to obtain a breakdown of the effectiveness of various techniques to improve the medication reconciliation process.
Conclusion
The results of this study show that clinicians sometimes overlook critical medications when collecting medication histories on hospital admission. It is essential to comprehend the significance of medication reconciliation to reduce medication-related adverse effects. In a lower middle-income nation where hiring pharmacists to conduct medication reconciliation would be an additional cost burden for hospitals, encouraging physicians to record medication history more precisely would be a more workable method. However, in situations where cost is not an issue, it is recommended to adopt evidence-based practices, such as integrating clinical pharmacists to lead medication reconciliation, which is the gold standard worldwide.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The Ethical Review Committee (ERC) of the hospital approved this study (reference number: 2022-7429-21437).
Footnotes
SF, AA, AZ, SF, AR, SN and HZ contributed equally.
Contributors SF1 and AA developed the study design and methodology. AZ acquired ethics approval for the project. SF1, AZ and SN collected study data. SF2 and AR analyzed all the study data. SF1, AZ and SF2 wrote the initial manuscript draft. SF1, AA and HZ reviewed the initial manuscript. SF1 and SF2 edited the initial manuscript. SF1, AA and HZ provided leadership for the research. SF1 is the guarantor of the content.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.