Implementation and Impact of Pharmacist-Initiated Home Medication Ordering in an Emergency Department Observation Unit.

Purpose: To design and evaluate the accuracy and efficiency of a medication reconciliation workflow incorporating pharmacist home medication ordering.

Methods: Designed and implemented an admission medication reconciliation workflow that expanded the pharmacists' role to include an initial ordering of home medications. Performed a prospective, pre-post cohort analysis comparing preimplementation accuracy and efficiency data from inpatient medicine and cardiology patients to postimplementation accuracy and efficiency data from our emergency department observation unit. Accuracy for the preimplementation group was defined by the number of unintentional discrepancies identified by pharmacists between the prescriber admission orders and the reconciled home medication lists. Accuracy for the postimplementation group was defined by the prescriber acceptance of pharmacist-ordered home medications. Efficiency was measured by pharmacist time to complete the admission medication reconciliation process.

Results: Prescribers accepted 98% of home medication orders placed by pharmacists, which correlated with a significant decrease in the occurrence of home medication orders containing a medication-related problem or discrepancy (46.4% vs 1.3%, < .0001). The mean pharmacist time spent completing medication reconciliation per admission decreased from 64 to 23 minutes ( < .0001).

Conclusion: Implementation of an admission process that incorporates pharmacist ordering of home medications increased prescribing accuracy and efficiency.