Implementation of a pharmacist resident medication reconciliation program

Purpose: The objectives of this study were to describe opportunities and barriers to establishing a medication reconciliation program operated by a college-based pharmacist resident at a tertiary hospital. Methods: A pharmacist resident rotating on the telemetry floor piloted the medication reconciliation program by providing services 2–3 days per week for 4 weeks for a total of 10 days. The resident participated on medical rounds with the cardiology consult service. All patients were offered the reconciliation program. A list of patients admitted was obtained from the institution’s list of admissions; discharge counselling services were initiated by the pharmacy resident, medical team or nursing. The number and type of interventions rendered as well as challenges to the implementation are described. Results: Fifty-six admission histories and 40 discharge counselling sessions were provided. The most frequent opportunity was related to interventions; 56 interventions were made. The most common interventions were improper documentation of allergies or medications (N = 26, 46.4%) and not starting a previous medication (N = 20, 35.7%). Non-cardiac medications accounted for 67.9% of interventions. The barriers included that the pharmacy resident provided part-time coverage; therefore, not all patients were educated and fewer interventions were made. Another barrier was related to health literacy. Over 80% of patients did not have a medication list and did not kn Purpose: The objectives of this study were to describe opportunities and barriers to establishing a medication reconciliation program operated by a college-based pharmacist resident at a tertiary hospital. Methods: A pharmacist resident rotating on the telemetry floor piloted the medication reconciliation program by providing services 2–3 days per week for 4 weeks for a total of 10 days. The resident participated on medical rounds with the cardiology consult service. All patients were offered the reconciliation program. A list of patients admitted was obtained from the institution’s list of admissions; discharge counselling services were initiated by the pharmacy resident, medical team or nursing. The number and type of interventions rendered as well as challenges to the implementation are described. Results: Fifty-six admission histories and 40 discharge counselling sessions were provided. The most frequent opportunity was related to interventions; 56 interventions were made. The most common interventions were improper documentation of allergies or medications (N = 26, 46.4%) and not starting a previous medication (N = 20, 35.7%). Non-cardiac medications accounted for 67.9% of interventions. The barriers included that the pharmacy resident provided part-time coverage; therefore, not all patients were educated and fewer interventions were made. Another barrier was related to health literacy. Over 80% of patients did not have a medication list and did not know the names of their medications. Conclusions: Pharmacist residents have many opportunities to impact patient care by conducting these services. The demand for such services may increase as pharmacist-provided medication reconciliation has been given increased national attention and since there is a push for increased pharmacist residency training. Given the limited resources, collaborations between college- and hospital-based pharmacy personnel are essential to optimize the services. ow the names of their medications. Conclusions: Pharmacist residents have many opportunities to impact patient care by conducting these services. The demand for such services may increase as pharmacist-provided medication reconciliation has been given increased national attention and since there is a push for increased pharmacist residency training. Given the limited resources, collaborations between college- and hospital-based pharmacy personnel are essential to optimize the services.