Longitudinal medication reconciliation at hospital admission, discharge and post-discharge

Background: Medication reconciliation (MR) is a widely recognised method to promote patient safety. However, its implementation is generally limited to an interaction at a single transition point. Objectives: To examine the rates and types of changes implemented in patient's medication regimens when MR is performed longitudinally at hospital admission, discharge and post-discharge, and to assess the clinical impact. Methods: A prospective multicentre cohort study was conducted in two hospitals. Patients received MR at admission, discharge and within five days post-discharge at home. Data was collected on rates and types of changes implemented in their medication regimens, due to MR, at all three transition points. These changes entailed corrections of unintentional discrepancies, e.g., between patients' actual medication use and physician prescriptions, and optimisations of pharmacotherapy, e.g., adding laxatives when opioids are prescribed. Using a validated instrument, the clinical impact of all medication changes were scored. Data were analysed using descriptive statistics. Results: In total, 197 patients with a median age of 73 years were included. In 86.3% of patients at least one change was implemented in the medication regimen due to longitudinal MR. At admission, discharge and post discharge, changes in medication regimens were necessary in 66.5%, 62.9% and 52.8% of patients, respectively. At admission and post-discharge, mainly unintentional discrepancies were corrected, and at discharge mainly optimisations were implemented. Implemented medication changes, due to longitudinal MR, prevented potential harm in 161 patients (81.7%). Potentially serious medication errors were most often prevented at hospital discharge, and predominantly involved optimising antithrombotic agents. Conclusions: Changes in medication regimens were implemented in 86.3% of patients due to longitudinal MR at admission, discharge and post-discharge. The rates and types of medication changes vary over time. Hospital discharge is an important moment for optimising pharmacotherapy.