1Clinical Pharmacist, Department of Hospital Pharmacy, DHRC, Jhapa, Nepal.
4Department of Internal Medicine, DHRC, Jhapa, Nepal
2,3Pharmacist, Department of Hospital Pharmacy, Damak Hospital, Jhapa, Nepal.
5Pharmacist, Department of Hospital Pharmacy, Lifeline Hospital, Jhapa, Nepal.
Objectives: The aim of this study was to assess the frequency and characteristics of discharge medication discrepancies and medication errors as identified during discharge with medication reconciliation. Methods: From June 2024 to January 2025, a prospective study was performed at Damak hospital in general medicine department, a primary care hospital in Damak, Jhapa. The information from discharge prescriptions as compared to the medication administration record (MAR), medication history taken at the time of admission was analyzed by the pharmacist before discharge. Results: Pharmacists performed 504 discharge medication reviews 65.47% (330 patients) had discrepancies in their prescriptions. 24.84% of patient lies in (18-39yrs). Notably, 38.48% of the patients were aged above 60, emphasizing the vulnerability of geriatric individuals for developing chronic diseases. The presence of polypharmacy is a key factor in the occurrence of medication discrepancies. Among the 504 patients in the study, 283(56.15%) patients has polypharmacy condition more than five drugs in a prescription and 221(43.85%) patients has less than 5 drugs. Out of the 330 discrepancies identified during discharge, 56.07% (185 discrepancies) were intentional, and 43.93% (145 discrepancies) were unintentional. The majority of patients (43.63%) had two comorbid conditions, followed by those with one comorbidity (29.09%). Conclusion: Lack of medication reconciliation can cause significant medication errors, which might be serious and cause harm to patients. This study has the potential to shape policies and practices that prioritize medication safety and optimize patient outcomes during transitions of care.
Medication reconciliation by pharmacists during patient discharge is a critical process that aims to ensure the safe and effective transition of care from the hospital to the patient's home [1]. It involves a comprehensive review and comparison of the medications the patient was taking prior to admission with the medications prescribed at the time of discharge. The pharmacists play a key role in this process, as they work closely with the healthcare team to identify and resolve any discrepancies, such as dose errors, omissions, or duplications [1,2]. During the patient discharge process, medication reconciliation by pharmacists serves multiple purposes. Firstly, it helps prevent adverse drug events and medication-related problems that can occur when patients receive conflicting prescriptions [3]. By carefully reviewing the medication list, the pharmacist can identify any potential drug interactions, allergies, or contraindications, ensuring that the prescribed medications are safe and appropriate for the patient's condition and that the way of taking medications is fully understood by the patient [3,5]. Secondly, medication reconciliation facilitates effective communication and coordination among healthcare providers, as it is a team-based work requiring the expertise and time of multiple health care providers to prevent medication errors and help the patient and his caregivers determine what the newly added and discontinued medications need to be after discharge [6,7]. Clinical pharmacists are health professionals with expertise in evaluating and monitoring all steps of medication use process to improve patient care and counsel health-care members. Several studies have demonstrated that the clinical pharmacists can effectively detect medication errors and take necessary actions by close collaboration with medical teams to reduce medication errors [8] .No study has yet evaluated the role of pharmacists in the identification and reduction of medication errors in Eastern Nepal . The present study was designed to determine the frequency, type and seriousness of medication errors and the role of pharmacist in the detection and correction of medication errors with the help of medication reconciliation. Hospital pharmacists have the expertise to address DRPs during and after hospitalization. They can counsel patients at discharge, detect and resolve medication discrepancies, and screen for nonadherence and ADEs after discharge. Data suggest that counseling patients before discharge reduces medication discrepancies. [9,10] and improves adherence.[9,11] Pharmacist follow-up after discharge has mixed effects on ED visits, hospital readmissions, and costs,[12] and effects of pharmacist interventions on ADEs after discharge are unknown. The study findings would draw the attention of health officials to the essential role of pharmacists in discharge medication reconciliation. It can provide valuable insights and evidence to drive improvements in patient safety, healthcare quality, and health system effectiveness. It has the potential to shape policies and practices that prioritize medication safety and optimize patient outcomes during transitions of care. This study aimed to evaluate the role of the pharmacist-led medication reconciliation service in primary hospital during discharge to identify and address potential medication discrepancies.
Study design
This prospective study was conducted in a General medicine department in primary care hospital(50 beded). A pharmacist evaluated all steps of medication use process including prescribing, transcribing, dispensing, administering, and monitoring under the supervision of a clinical pharmacist to find medication errors. All prescriptions of discharged patients were analyzed. The medication were cross checked with the patients providing medication list obtained from medical administration record and medication history taken at the time of admission. The duration of the study was 8 months (from June 2024 to january 2025). The protocol of the study was reviewed and approved by the ethics committee of the hospital.
Inclusion Criteria
The inclusion criteria were patients (above 18 years) who were discharged from wards, received a written discharge prescription from the physician, and had five or more medications within their discharge medications. The study included patients with five or more medications when discharged who could be at high risk for medication-related problems and drug-drug interactions since including all patients requires more human resources . The patients were interviewed after obtaining their verbal consent to record their demographics, discharge medications, medical history, medication history, and diagnosis.
Exclusion criteria
Pregnant and lactating women, pediatric patients ,
Statistical analysis
Statical analysis was done by data entry in to MS EXCEL 2019 and analyzed. Descriptive statistics were expressed in term of actual number and percentage.
RESULT
Demographic Characteristics
Out of the 504 patients included in the study, 65.47% (330 patients) had discrepancies in their prescriptions. 24.84% of patient lies in (18-39yrs). Notably, 38.48% of the patients were aged above 60, emphasizing the vulnerability of geriatric individuals for developing chronic diseases. Detailed demographic information of the subjects can be found in Table 1.
Table 1: Demographics of Subjects
|
Age (Yrs) |
Male (N=121) |
Female (N=209) |
Total (N=330) |
|
18-39 |
25(20.66%) |
57(27.27%) |
82(24.84%) |
|
40-59 |
45(37.19%) |
76(36.36%) |
121(36.66%) |
|
60 above |
51(42.14%) |
76(36.36%) |
127(38.48%) |
Number of Co-Morbidities
The study explores the relationship between comorbid conditions and medication discrepancies. Evidence suggests that as the number of comorbid conditions increases, the number of prescribed medications also rises, potentially leading to intentional or unintentional medication discrepancies on charts. In this study, comorbidities were identified. The majority of patients (43.63%) had two comorbid conditions, followed by those with one comorbidity (29.09%). A detailed breakdown of the quantity of comorbidities can be found in Table 2.
Table 2: Number of Co-Morbidities
|
No of co-morbidities |
No of co- morbidities per subject(n=330) |
|
1 |
96(29.09%) |
|
2 |
144(43.63%) |
|
3 |
67(20.30%) |
|
4 |
23(6.96%) |
Number of Medications per Prescription
Effective medication reconciliation relies on obtaining a patient's past medication history. The presence of polypharmacy is a key factor in the occurrence of medication discrepancies. Among the 504 patients in the study, 283(56.15%) patients has more than five drugs in a prescription and 221(43.85%) patients has less than 5 drugs. Table 3 illustrates the distribution of Medication per prescriptions. These findings will be valuable for assessing the association of past medication history (Table 3) with medication discrepancies.
Table 3: No. of Medications per Prescription
Category of Discrepancies
In this study, medication discrepancies were classified as intentional and unintentional. Intentional discrepancies involved medication changes based on evolving clinical status, while unintentional discrepancies included issues like omission or duplication. Out of the 330 discrepancies identified during discharge, 56.07% (185 discrepancies) were intentional, and 43.93% (145 discrepancies) were unintentional. Table 4 provides a breakdown of these categories.
Table 4: Category of Discrepancies
|
Category Of Discrepancy |
No Of Patients(N=330) |
|
Un- Intended |
145(43.93%) |
|
Intendent |
185(56.07%) |
Type of un- Intentional Discrepancies
Of the 145 unintentional medication discrepancies identified during patient discharge, the most type of medication discrepancy was a changing frequency of medication by 54(37.24%), followed by dose changed by 31 (21.37%), and omission of drug by 26(17.44%).
Table 5: Type of un- Intentional Discrepancies
|
Types of discrepancies |
No of unintended discrepancies at the time of admission(n=145) |
|
Omission |
26(17.44%) |
|
changed dose |
31(21.37%) |
|
changed frequency |
54(37.24) |
|
changed route |
19(13.10%) |
|
wrong duration |
7(4.82%) |
|
Commission |
12(8.27%) |
Class of Medication found with un-Intentional Discrepancy
Unintentional drug discrepancies were linked to an increased number of drugs. Patient prescribed with calcium channel blocker has more discrepancies (19.31%).Inhalation drugs ,Antimicrobial drugs, calcium supplements has ( 18.62%) ,(15.86%), (13.10%) respectively.
Table 6: Class of Medication found with un-Intentional Discrepancy
|
Class of medications in unintentional discrepancies(n=145) |
No of Drugs |
|
Inhalation drugs |
27(18.62%) |
|
CCB's |
28(19.31%) |
|
oral hypoglycemic drugs |
11(7.58%) |
|
Statin |
9(6.20%) |
|
Antimicrobial |
23(15.86%) |
|
Beta -Blockers |
7(4.82%) |
|
Calcium supplements |
19(13.10) |
|
NSAIDS |
13(8.96%) |
|
Others |
8(5.51%) |
Classification of Severity of Medication Errors According to NCC-MERP Guidelines
Assessing the severity of medication errors is vital for patient safety. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) was used to categorize error severity. The findings showed that the majority of errors, accounting for 44.54%, were under Category C, indicating errors that reached the patient but did not cause harm. Additionally, Category D, representing errors that reached the patient but required monitoring to confirm no harm, made up 27.87% of observed errors.
Table 7: Severity of Medication Errors
|
Severity of medication Error |
No of Prescription(n=330) |
|
Cat A |
0 |
|
Cat B |
55(16.66%) |
|
Cat C |
147(44.54%) |
|
Cat D |
92(27.87%) |
|
Cat E |
37(9.39%) |
|
Cat F |
5(1.51%) |
|
Cat G |
0 |
|
Cat H |
0 |
|
Cat I |
0 |
DISCUSSION
The term “medication reconciliation” (review, counseling and addressing) has been very well known in developed countries; However, it is still not widely implemented nor enforced in our healthcare settings of our country. Comprehensive medication reconciliation by a pharmacist during hospital discharging has been shown to be an effective process to reduce medication discrepancies and errors[13]. pharmacist involvement in discharge reconciliation, which revealed that the most common errors during discharge were of significant severity. Our findings revealed different reasons for unintended medication discrepancies identified during discharge. The most common medication discrepancy was by changing frequency(37.24.%), Even we can see duplication of the same medication with different manufacturers or different medications from the same pharmacological class this might due to changing brands of medicines by the hospital running government insurance facilities which purchase the medicines in contract basis with drugs distributors. Another main cause is limited health literacy in Nepal when patients cannot recognize the medication names of different manufacturer companies and think that a different pack is a different medication. Additionally, this could be due to the involvement of multiple healthcare providers in the prescribing process and a lack of communication between them . Pharmacy-related issues can also occur during the dispensing process by an external community pharmacy, such as substitution errors since most discharge medications are not available in public hospitals. The most common duplicated medications were statins, oral hypoglycemic agents, and combination antihypertensive drugs. This could happen during drug switching or because of trade names. Writing trade names can cause more confusion at the prescribing and dispensing stages compared to generic names . Additionally, this could be due to multiple healthcare providers or a lack of communication or counseling [14]. As in previous Iraqi studies [15,16], it demonstrated the importance of physician -pharmacist collaboration to prevent potential medication errors. Our study shows that the public hospital has not enforced pharmacist -led reconciliation process at discharge, and some hospital pharmacists may believe this review process is voluntary unless the patient is asking for it. This study involving 504 patients found a slightly higher percentage of female and a majority aged over 60, emphasizing the need to address healthcare for older individuals. In contrast, Meda V.S. et al.'s study of 106 participants reported 42% men and 58% women, with 63% over 60. The current study, with its larger sample size and focus on prescription accuracy, provides a more comprehensive understanding of patient demographics and healthcare quality. These findings highlight the necessity of reconciling healthcare for older patients and ensuring precise medication administration to enhance patient care and safety. The present study analyzed a total of 784 comorbidities, most patients had two comorbidities followed closely by those with one. This suggests that many patients have multiple health issues simultaneously, thereby complicating their medical care. Ahamed Bilaal et al’s study echoes this pattern, finding that a high percentage of patients (47.84%) had two or more comorbidities when admitted to the hospital. In our study, majority were considered intentional, meaning they were planned medication changes, while others were unintentional, indicating they weren't part of the original plan. In Mattia Del toset al.'s study, 367 discrepancies were identified at hospital , out of which 314 were intentional and 53 unintentional discrepancies were found which was similar with our study.[18] This study revealed that drug omission was the most common type of error during admission where as in my study changing frequency (37.24%) which was different in our study. Medication discrepancies were classified based on their severity using a standard system called the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) classification. Current study revealed that the majority of errors fell into Category C which means error reached the patient but didn't cause any harm. The next most common category was Category D where errors reached the patient but required monitoring to ensure no harm occurred. In contrast, Meda VS et al.'s study found that a majority of errors belonged to Category E (53%). This category suggests that these errors may result in temporary harm to the patient.
Limitations of the Study
The study had some limitations. The study was limited to the Internal Medicine ward at a single hospital in Jhapa, which may restrict the study's generalizability. Furthermore, the sample size and period of time was relatively small. However, the sample included patients with multiple medications, who might be particularly prone to discrepancies during the transition of care. Future studies can include all patients in the reconciliation service, which needs more human resources. In other words, covering more patients needs a larger number of pharmacists and more pharmacist time dedicated for this service.
CONCLUSION
Medication reconciliation by a pharmacist is pivotal to resolving potential medication errors throughout the care transition from hospital to home, especially for patients with multiple medications, and in collaboration with the medication counseling or education performed by the physician. Theoretically, medication reconciliation is adopted by public hospitals, but it needs to be enforced as routine work for hospital pharmacists since it enhances patient medication safety. Most of the patients age were above 60 which means number of admitted patients will be of chronic condition and lack of knowledge of medicines on them shows especial care to them with providing sufficient pharmacist to them. Pharmacist counseling, Medication reconciliation and follow-up were associated with lower rates of preventable ADEs after discharge, likely through reduction in medication discrepancies. Greater roles for pharmacists in hospital care should be considered, especially as medication reconciliation becomes mandatory. Future studies should focus on optimizing these interventions, identifying patients most likely to benefit from pharmacist involvement, and studying and improving cost-effectiveness. The existing counseling service provided to patients upon discharge is inadequate and needs to be improved. Pharmacists can play a vital roles in obtaining better health outcomes of patients.
Conflict of interests: No conflict of interest was declared by the authors.
Funding source: The authors did not receive any source of fund.
REFERENCES
Amish Uprety*, Reshav Baral, Nabin Ghimire, Dr. Shubh Narayan Byar, Sunanda Sharma, To Evaluate the Role of Pharmacist in Medication Reconciliation on Discharge Patients in A Primary Hospital: An Observational Study, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 2, 463-470. https://doi.org/10.5281/zenodo.14831626
10.5281/zenodo.14831626
