Vol. 2, Issue 1, Part A (2025)

Background: Medication discrepancies and adverse drug events (ADEs) remain major causes of preventable harm in hospitalized patients, particularly during transitions of care such as admission and discharge. Pharmacist-led medication reconciliation (MedRec) has emerged as a key intervention to enhance medication safety by ensuring the accuracy and continuity of drug therapy.
Objective: To evaluate the impact of pharmacist-led medication reconciliation on the incidence of medication discrepancies and adverse drug events in a tertiary care hospital setting, compared with standard physician-led medication review.
Methods: A prospective comparative study was conducted over 12 months among 300 inpatients (150 in the intervention group and 150 in the control group) admitted to the medicine and surgery departments of a tertiary care teaching hospital. In the intervention group, clinical pharmacists obtained a Best Possible Medication History (BPMH), compared it against admission and discharge prescriptions, identified discrepancies, and resolved them through physician collaboration. The control group received standard care without pharmacist involvement. Outcomes measured included the number and type of discrepancies, incidence of ADEs, length of hospital stay, and 30-day readmissions. Statistical analysis was performed using Student’s t-test, Chi-square test, and logistic regression with a significance threshold of p < 0.05.
Results: Pharmacist-led reconciliation reduced the proportion of patients with at least one discrepancy from 64.0% to 28.0% (p < 0.001) and decreased the mean number of discrepancies per patient from 1.27 ± 1.1 to 0.52 ± 0.8. The incidence of in-hospital ADEs was significantly lower in the pharmacist-led group (9.3%) compared with the control group (22.7%) (p = 0.002). Preventable ADEs declined by 20%, and average hospital stay was shortened by 0.8 days (p = 0.045). Logistic regression confirmed that absence of pharmacist intervention independently predicted ADE occurrence (OR = 2.48; 95% CI 1.25-4.92).
Conclusion: Pharmacist-led medication reconciliation effectively minimizes medication discrepancies and adverse drug events, improves therapeutic accuracy, and optimizes resource utilization in tertiary care hospitals. Institutionalizing this intervention as a standard clinical practice can significantly strengthen patient safety and overall healthcare quality.