Reeder TA, Mutnick A
Am J Health Syst Pharm. 2008;65:857-860
About 60% of hospitalized patients have at least 1 error in their medication history that is taken upon admission. The investigators in this study compared medication histories that were obtained by hospital pharmacists with those obtained by physicians. The study was prospective and included 55 patients, age 18 or older, admitted to the internal medicine service at a major teaching hospital. Within several hours of admission, a physician from the internal medicine service obtained a medication history from the patient as part of the overall history and physical examination. Subsequently, within 24 hours of admission, a pharmacist interviewed patients to obtain additional relevant medication history, such as dosages, dosing schedule, use of nonprescription medications and supplements, allergies, pregnancy and lactation status, and vaccination status. Pharmacists identified a total of 353 discrepancies between the pharmacist-obtained history and that obtained by the physician. For example, they identified 614 medications being used by patients, whereas the physicians identified only 556 (P < .001). Pharmacists also documented significantly more doses and dosing schedules than did physicians, and documented allergies and vaccinations more consistently.
Pharmacists contacted the admitting physician to intervene on 161 discrepancies, and 88% of those differences were either corrected or justified by the respective physician. This study demonstrates that when pharmacists conducted medication histories, more complete information was obtained. The authors concluded that physicians may be omitting important parts of the medication history, including drugs taken prior to admission, drug doses, dosage schedules, allergies, and vaccination status.
A significant challenge facing all health professionals, medical centers, physician practices, and health systems is assuring that accurate and complete patient medication histories are obtained at the point of service. Medication histories that are incomplete or inaccurate can lead to interruptions in drug therapy and/or inappropriate prescribing during a hospital admission. This may place patients at risk for drug-related complications, such as prolonged hospitalization or increased mortality. Unfortunately, obtaining a thorough and accurate medication history can be time-consuming, and it requires special expertise. Few hospitals currently engage pharmacists to obtain a patient's medication history upon admission.
Pharmacists are trained to probe patients for specific medication information, including any drugs used "prn" or "as needed," over-the-counter drugs, vitamins, herbs, and dietary supplements, along with the specific dose and dosing schedule for each. Pharmacists can readily identify incorrect or fictitious drugs or dosages, and they can inquire about drug allergies and the clinical manifestations of a reported allergy. One area that often is overlooked is the patient's adherence to a prescribed drug regimen; this may require a phone call to the patient's pharmacy to verify refill patterns.
Although these and other key parts of the medication history (eg, pregnancy, lactation, and vaccination status) may be obtained by physicians, nurses, or other providers, pharmacists are best qualified to identify discrepancies and intervene with the responsible physician. In doing so, pharmacists may prevent subsequent medication mishaps. Examples include the omission of a clinically indicated drug upon hospital admission, an inappropriate dose given, or the recognition of a drug-induced adverse effect being manifest upon admission.
In conclusion, I strongly agree with the authors' statement that "pharmacists must begin to take a more active role in the medication reconciliation process." Unfortunately, the most common reasons cited for not involving pharmacists in admission histories is a lack of time or pharmacist personnel.
Reviewed by Ramaz Mitaishvili, MD
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