Nursing home residents are at risk for medication errors when being transferred between wards. Medication reconciliation is a process used to verify medication use, identify variations and rectify medication errors during transitions. This pilot study was performed to evaluate a pharmacist-directed medication-reconciliation program in a nursing home setting. The number and types of discrepancies 3 months before (the control period) and after (the study period) implementation of a medication-reconciliation program were compared. A pharmacist performed medication reconciliation and discussed discrepancies with care providers in the study period. There were 190/209 (90.9%) and 220/266 (82.7%) documented discrepancies during the control and study periods, respectively. The major discrepancies found in both periods were the addition or omission of drugs. Of the 46 undocumented discrepancies in the study period, 13 (28.3%) were confirmed to be intentional changes. The suggestions made by the pharmacist were accepted in 19 of the remaining 33 undocumented (and unintentional) discrepancies. Eleven of 12 harmful discrepancies in the study period were corrected in a timely manner as a result of the medication- reconciliation program, that is, 91.7% of the harmful discrepancies were successfully prevented. But five (26.3%) harmful unintentional discrepancies of the 19 undocumented discrepancies in the control period could not be prevented from affecting patients. Pharmacist-directed medication reconciliation can reduce medication discrepancies in a nursing home setting in Taiwan.
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