Evaluation of a Pharmacist-Driven Discharge Medication Reconciliation Service

Acknowledgments: The authors would like to acknowledge Bryan McCarthy, 2026 PharmD candidate, Florida A&M University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health.

Disclosures: The authors have nothing to disclose.

Abstract

Purpose

Medication reconciliation is a systematic process utilized to ensure the accuracy and consistency of a patient’s medication information across transitions in care. It involves comparing the patient’s current medication regimen with the prescribed medications to identify and resolve discrepancies, such as omissions, duplications, dosing errors, or potential drug interactions. Multiple studies have examined the impact that pharmacist-led medication reconciliation has on identifying medication errors, decreasing hospital readmission rates, and reducing emergency department (ED) visits. This study aims to further determine whether a pharmacist-led medication reconciliation service is beneficial for identifying and implementing clinical interventions.

Methods

This study is a retrospective quasi-experimental analysis of the effect of pharmacist-led medication reconciliation services performed by the internal medicine residency team prior to patient discharge at this facility. This study took place from April 2024 to October 2025 at Ascension Sacred Heart Pensacola. Patients were included in the study if they had a medication reconciliation completed by the pharmacy team prior to discharge. Patients were excluded if they were to be discharged to hospice care, comfort care, palliative care, a long-term acute care facility, or jail, or if their visit coincided with system downtime. Additionally, patients who remained in the ED for the duration of their admission, were discharged more than 24 hours after medication reconciliation was completed, or who left against medical advice were also excluded from the study. The primary objective of this study is to determine the average number of interventions identified per patient during the pharmacist-led discharge medication reconciliation for patients diagnosed or undiagnosed with diabetes, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). Secondary objectives included determining the total number of interventions accepted by the internal medicine residency team, identifying the type of interventions recommended, determining the total number and types of interventions identified among patients diagnosed with diabetes, COPD, and CHF, and comparing 30-day readmission rates with a similar group of patients prior to the initiation of the pharmacist-led medication reconciliation program.

Results

The average number of interventions identified per patient by the pharmacist-led discharge medication reconciliation service was 1.32. The 30-day readmission rate was approximately 44% lower in the postintervention group than in the preintervention group (relative risk [RR] 0.56; 95% CI, 0.27, 1.14; P value = .13). The total number of interventions accepted was 81 (61%). The most common intervention types identified were omission of therapy (21.2%) and therapy optimization (20.5%). The highest number of interventions identified (14) was in patients with diabetes.

Conclusion

Overall, pharmacist-driven discharge medication reconciliation services can identify clinical interventions and may contribute to a lower 30-day readmission rate.

Introduction

Medication reconciliation is a systematic process utilized to ensure the accuracy and consistency of a patient’s medication information across transitions in care. It involves comparing the patient’s current medication regimen with the prescribed medications to identify and resolve discrepancies, such as omissions, duplications, dosing errors, or potential drug interactions.

Multiple studies have examined the impact that pharmacist-led medication reconciliation has on identifying medication errors, decreasing hospital readmission rates, and reducing emergency department (ED) visits.^1-4 Further analysis of the exact clinical recommendations that pharmacists identify and execute through a pharmacist-led discharge medication reconciliation service is warranted. This study aimed to determine whether a pharmacist-led medication reconciliation service is effective at identifying and recommending clinical interventions.

Methods

This study is an Institutional Review Board–exempt retrospective quasi-experimental analysis evaluating the effect of pharmacist-led medication reconciliation services performed by an internal medicine (IM) residency team prior to patient discharge at a large academic medical center. This study took place from April 2024 to October 2025 at Ascension Sacred Heart Pensacola. For the preintervention group, comprising patients admitted before the pharmacist-led discharge medication reconciliation service was established, a chart review was conducted. For the postintervention group, patients were identified by the IM medical residents for discharge, and an assigned pharmacist conducted a discharge medication reconciliation. The pharmacist relayed recommendations to the IM medical residents and documented in an online spreadsheet the type of interventions recommended, whether the recommendations were accepted, and the rationale behind rejected recommendations.

Patients were included in the study if they had a medication reconciliation completed by the pharmacist prior to discharge. Patients were excluded if they were to be discharged to hospice care, comfort care, palliative care, a long-term acute care facility, or jail, or if their visit coincided with system downtime. Additionally, patients who remained in the ED for the duration of their admission, were discharged more than 24 hours after medication reconciliation was completed, or who left against medical advice were also excluded from the study.

The primary outcome of this study is the average number of interventions identified per patient during the pharmacist-led discharge medication reconciliation for patients with diagnosed or undiagnosed diabetes, chronic obstructive pulmonary disease (COPD), and/or congestive heart failure (CHF). Secondary outcomes include the total number of interventions accepted by the IM residency team; types of interventions recommended (omission of intended therapy, dose adjustment, duration adjustment, therapy optimization, duplicate therapy, contraindication, allergy, therapy not indicated, drug-drug interaction, route adjustment, frequency adjustment, formulation adjustment); total number and types of interventions identified among patients diagnosed with diabetes, COPD, and CHF; and a comparison of 30-day readmission rates between the 2 groups. Demographics were analyzed using descriptive statistics. The χ² test was used to compare the 30-day readmission rate between the pre- and postintervention groups, with an α level of 0.05 (5%). The relative risk of 30-day readmission was also calculated.

Results

There was a total of 100 participants in the preintervention group and 100 participants in the postintervention group. Baseline characteristics differed between the 2 arms, as indicated in Figure 1. The percentage of participants with chronic disease diagnoses, the average age, and the average length of admission were higher in the preintervention group.

The average number of interventions identified per patient by the pharmacist-led discharge medication reconciliation service was 1.32. This service produced a nonstatistically significant decrease in 30-day readmission by 44% in the postintervention group compared with the preintervention group (RR 0.56 [95% CI, 0.27, 1.14], P = .13; Figure 2). Of the 132 interventions identified, 81 were accepted by the IM residency team, displaying a 61% acceptance rate. The most common intervention types identified were omission of therapy (21.2%) and therapy optimization (20.5%) (Figure 3). The disease state with the highest number of interventions identified (14) was in patients with diabetes (Figure 4).

Discussion and Conclusion

Multiple studies have assessed the impact of pharmacist-led medication reconciliation services on patient health outcomes. A systematic review by Harris et al found that 123 studies reported a decrease in 30-day readmission rates upon initiation of pharmacy-led transitions of care programs.¹ A randomized controlled trial by Tasseff et al demonstrated a 7% decrease in the composite 30-day ED visit and hospital readmission rate among participants receiving extended standard of care compared with standard of care.²

In a study by Zheng et al, it was found that the average number of errors per patient identified by the pharmacist-led discharge medication reconciliation was approximately 1.3 and that the most common error was duplication of therapy, resulting in approximately 25% of all errors.³ Lastly, in a study by Jacobs et al, pharmacy interventions that included medication reconciliation, comprehensive medication review, and patient/provider follow-up reduced all-cause readmissions and ED visits within 30 days by approximately 46% in those who received said services vs those who did not.⁴

In this study, the 44% reduction in the 30-day readmission rate in the postintervention group compared with the preintervention group, which did not reach statistical significance, may be due to the study’s small sample size. The higher number of participants with older age, chronic disease diagnoses, and longer hospital stays in the preintervention group compared with the postintervention group, which may reflect more complicated clinical situations, may also contribute to the lack of statistical significance in this outcome. The lower acceptance rate by the IM residency team may stem from the hesitancy of inpatient providers to adjust maintenance regimens for chronic disease states, as these adjustments may be more appropriate for outpatient providers who can monitor medication adjustments with close follow-up. Other potential factors contributing to this lower acceptance rate may include a patient’s financial constraints, limitations in health insurance coverage, and poor health literacy, which may decrease the likelihood of regimen adherence. This study adds to the body of evidence supporting pharmacy’s positive impact on patient health outcomes, specifically in reducing 30-day readmission rates and identifying clinical interventions. This reinforces the benefit of a pharmacist-driven discharge medication reconciliation service.

As mentioned above, limitations of this study include a smaller sample size (N = 200), a higher number of patients with chronic disease diagnoses in the preintervention group, a higher average age in the preintervention group, and a longer length of admission in the preintervention group. For future research, a larger sample size and participants with more similar baseline characteristics could help mitigate confounding bias.

Overall, pharmacist-driven discharge medication reconciliation services provide the benefit of identifying clinical interventions and may contribute to a decreased 30-day readmission rate.

REFERENCES

1. Harris M, Moore V, Barnes M, Persha H, Reed J, Zillich A. Effect of pharmacy-led interventions during care transitions on patient hospital readmission: a systematic review. J Am Pharm Assoc. 2003;62(5):1477-1498.e8. doi:10.1016/j.japh.2022.05.017

2. Tasseff N, Axtell S, Nixon B. Effect of extended pharmacist involvement in discharge transitions of care on hospital readmission rates: prospective, randomized, parallel arm design trial. J Am Coll Clin Pharm. 2024;7(1):8-14. doi:10.1002/jac5.1887

3. Zheng L, Pon T, Bajorek S, et al. Impact of pharmacist-led discharge medication reconciliation on error and patient harm prevention at a large academic medical center. J Am Coll Clin Pharm. 2024;7(8):787-794. doi:10.1002/jac5.1980

4. Jacobs DM, Slazak E, Daly CJ, et al. Clinical and economic effectiveness of a pharmacy and primary care collaborative transition of care program. J Am Pharm Assoc (2003). 2023;63(6):1722-1730.e3. doi:10.1016/j.japh.2023.08.014