Impact of Clinical Pharmacist-Led Medication Reconciliation on Patient Safety

Abstract

Medication-related discrepancies are a significant patient-safety concern, particularly during transitions between healthcare settings. Differences between a patient's actual medication use and the medication information documented in hospital records may result in omissions, duplications, incorrect doses, drug interactions, and other medication-related problems. Clinical pharmacists possess specialized knowledge of pharmacotherapy and can contribute substantially to the identification and resolution of these discrepancies. This paper examines the impact of clinical pharmacist-led medication reconciliation on patient safety, with particular attention to medication discrepancies, adverse drug events, emergency department visits, hospital readmissions, and continuity of care. Medication reconciliation involves obtaining the most accurate medication history, comparing medication information across healthcare sources, identifying discrepancies, resolving clinically important differences, and communicating the updated medication plan. Evidence from systematic reviews indicates that pharmacist-led interventions can reduce medication discrepancies and may improve selected post-discharge outcomes. A systematic review and meta-analysis involving 17 studies and 21,342 adults reported reductions in adverse-drug-event-related hospital revisits, emergency department visits, and hospital readmissions among patients receiving pharmacist-led reconciliation programs, although effects on mortality were not significant. Other evidence indicates that the effectiveness of medication reconciliation varies according to intervention design, setting, timing, and whether reconciliation is combined with additional transition-of-care services. Clinical pharmacists therefore represent an important component of multidisciplinary medication-safety programs. Effective implementation requires standardized procedures, access to reliable medication histories, communication among healthcare professionals, patient participation, and continuous evaluation of outcomes.