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

Background: Transitions of care, particularly at hospital discharge, are critical points for medication safety, where unintentional discrepancies and prescribing errors commonly occur. Pharmacist-led medication reconciliation has emerged as a validated strategy to minimize preventable medication errors and optimize therapeutic outcomes.
Objective: This study aimed to evaluate the impact of pharmacist-led medication reconciliation on preventable medication errors at hospital discharge compared with standard discharge practices, using standardized assessment tools such as the WHO-UMC causality scale and the NCC MERP error classification system. Secondary objectives included analyzing drug-related problems (DRPs), potentially inappropriate medications (PIMs), 30-day readmissions, and cost-avoidance outcomes.
Methods: A prospective comparative study was conducted over six months in a tertiary care hospital involving 240 patients, randomized equally into a control group (standard discharge) and an intervention group (pharmacist-led reconciliation). Medication discrepancies were identified, categorized using NCC MERP, and causality assessed using WHO-UMC. PIMs were determined using Beers and STOPP/START criteria, and DRPs were classified according to PCNE guidelines. Statistical analysis employed chi-square and t-tests, with p < 0.05 considered significant.
Results: The pharmacist-led group demonstrated a 57.9% reduction in total discharge medication discrepancies (74 vs. 176; p < 0.001). The mean number of discrepancies per patient decreased from 1.47 to 0.62, while severe errors (NCC MERP categories C-E) were significantly fewer in the intervention group. DRPs were reduced from 139 to 61, and PIM prevalence among elderly patients (≥65 years) decreased from 40% to 20.7%. Thirty-day readmission rates showed a declining trend (17.5% vs. 9.2%), reaching statistical significance in high-risk subgroups (p = 0.04). The intervention also yielded favorable cost-avoidance outcomes consistent with published economic models.
Conclusion: Pharmacist-led medication reconciliation at discharge substantially reduces preventable medication errors, enhances medication safety, decreases DRPs and PIMs, and potentially lowers readmissions and healthcare costs. Incorporating pharmacists as integral members of discharge teams should be a standard practice in hospital care systems to ensure safe and effective transitions of therapy.