Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model.

PURPOSE: The development, implementation, and pilot testing of a discharge medication reconciliation service managed by pharmacists with offsite telepharmacy support are described. SUMMARY: Hospitals' efforts to prepare legible, complete, and accurate medication lists to patients prior to discharge continue to be complicated by staffing and time constraints and suboptimal information technology. To address these challenges, the pharmacy department at a 324-bed community hospital initiated a quality-improvement project to optimize patients' discharge medication lists while addressing problems that often resulted in confusing, incomplete, or inaccurate lists. A subcommittee of the hospital's pharmacy and therapeutics committee led the development of a revised medication reconciliation process designed to streamline and improve the accuracy and utility of discharge medication documents, with subsequent implementation of a new service model encompassing both onsite and remote pharmacists. The new process and service were evaluated on selected patient care units in a 19-month pilot project requiring collaboration by physicians, nurses, case managers, pharmacists, and an outpatient prescription drug database vendor. During the pilot testing period, 6402 comprehensive reconciled discharge medication lists were prepared; 634 documented discrepancies or medication errors were detected. The majority of identified problems were in three categories: unreconciled medication orders (31%), order clarification (25%), and duplicate orders (12%). The most problematic medications were the opioids, cardiovascular agents, and anticoagulants. CONCLUSION: A pharmacist-managed medication reconciliation service including onsite pharmacists and telepharmacy support was successful in improving the final discharge lists and documentation received by patients.

Providing nighttime pharmaceutical services through telepharmacy.

A nighttime telepharmacy service serving a community hospital is described. At a 340-bed acute care community hospital, the level of nighttime activity related to medication use did not support the establishment of a full night pharmacy shift. After-hours access to medications was mostly the responsibility of nursing and medical staff using a separate night closet, automated dispensing machines, and limited floor stock. Pharmacists reviewed new orders and missing doses during the following day shift. An innovative practice model that combined an outsourced telepharmacy service and the traditional oncall pharmacist service was implemented to improve services at night. Prospective order review, drug information services, and clinical pharmacy consultations were all provided under the new model. Nurses and physicians used the service extensively. A total of 1039 drug orders were reviewed by the telepharmacy service during the first three months, with 29% of these orders representing high-risk therapies. Most orders were submitted by the critical care areas, the medical-surgical units, and the emergency department. Feedback from the hospital staff concerning the service was favorable, and physician leaders asked that the service be expanded to take oral orders from physicians at night. A nighttime telepharmacy service was successfully implemented at a community hospital to provide medication order review, resolution of drug-related problems, and drug information and clinical pharmacy services.