Evaluation of a Pharmacist-Driven Discharge Medication Reconciliation Service Pilot at a Children's Hospital.

Objective: The purpose of this study was to evaluate the feasibility of a pharmacist-driven discharge medication reconciliation (DMR) service at our children's hospital by completing a 2-week pilot on a general pediatrics unit.

Methods: This was a prospective study and included patients discharged during pilot hours whose DMR was completed by the pharmacist. The primary outcome was evaluation of time required for a pharmacist to complete the DMR. Secondary outcomes included classification of pharmacist interventions made and their associated cost-avoidance, medication-related problems reported within 14 days of discharge, hospital readmission due to medication problems within 30 days of discharge, and medical resident satisfaction assessed via prepilot and postpilot surveys.

Results: A total of 67 patients had their DMR completed by a pharmacist during the pilot. The pharmacist spent an average of 30 minutes completing each DMR, although this was variable, as evidenced by an SD of 36.4 minutes. Pharmacists documented 89 total interventions during the study period. The most common intervention types were therapeutic optimization (32.6%) and modification of directions (29.2%). Total estimated cost-avoidance during the study pilot was $84,048.01. For the pilot population, 1 medication-related problem was identified within 14 days of discharge. There were no medication-related readmissions identified. Medical residents reported increased confidence that the DMR was completed accurately and satisfaction with the DMR process during the pilot compared with before the pilot.

Conclusions: Implementing a pharmacist discharge medication service requires consideration of -pharmacist time and salary, which may be offset by cost-avoidance.